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Background Medical education has been criticised for not adapting to changes in society, health care and technology. Internationally, it is necessary to strengthen primary health care services to accommodate the growing number of patients. In Norway, emergency care patients are increasingly treated in municipal emergency care units in the primary health care system. This study explores medical students’ learning experience and how they participated in communities of practice at two municipal emergency care units in the primary health care system. Methods In this qualitative study, we collected data from March to May 2019 using semi-structured individual interviews and systematic observations of six ninth-semester medical students undergoing two-week clerkships at municipal emergency care units. The interview transcripts were thematically analysed with a social constructivist approach. A total of 102 systematic observations were used to triangulate the findings from the thematic analysis. Results Three themes illuminated what the medical students learned and how they participated in communities of practice: (i) They took responsibility for emergency care patients while participating in the physicians’ community of practice and thus received intensive training in the role of a physician. (ii) They learned the physician’s role in interprofessional collaboration. Collaborating with nursing students and nurses led to training in clinical procedures and insight into the nurses’ role, work tasks, and community of practice. (iii) They gained in-depth knowledge through shared reflections when time was allocated for that purpose. Ethical and medical topics were elucidated from an interprofessional perspective when nursing students, nurses, and physicians participated. Conclusions Our findings suggest that this was a form of clerkship in which medical students learned the physician’s role by taking responsibility for emergency care patients and participating in multiple work tasks and clinical procedures associated with physicians’ and nurses’ communities of practice. Participating in an interprofessional community of practice for professional reflections contributed to in-depth knowledge of ethical and medical topics from the medical and nursing perspectives.

Myocardial infarction is an acute, frightening and life-threatening condition for patients who are affected. They need plain and simple information about the disease and the treatment, yet patient participation might be challenging in acute situations. Previous studies have shown that patient participation leads to improved patient satisfaction, cooperation with healthcare professionals and better management of the disease. Physicians have a key role in facilitating patient participation in the healthcare services. This study explores physicians’ perceptions of patient participation in the myocardial infarction pathway. In 2018 we interviewed nine experienced physicians in Norway working in different phases of the pathway. Hermeneutics was chosen as the underpinning analytical framework. Four themes illustrated patient participation in the myocardial infarction pathway. Paternalism characterised the acute phase. During hospitalisation the physicians perceived a lack of continuity in physician–patient communication. In the discharge phase, the physicians focused on strengthening health literacy. In the rehabilitation phase, dialogue and shared decision making was central to achieving treatment adherence. We found variations in the level of patient participation along the different phases of the myocardial infarction pathway. Strengthening continuity to ensure patient participation and collaboration between healthcare professionals is essential. The physicians proposed introducing checklists for patient information to enhance interprofessional collaboration and strengthen patient participation.

Background Providing care to older individuals with complex needs and patients with chronic illness is a concern worldwide. In Norway, this situation led to the transfer of responsibility for care and treatment to the municipalities. Providing emergency care at the municipal level – thereby reducing the need for emergency hospital admissions – is part of the Coordination Reform in Norway. This reform from 2012 warrants a reconsideration of which nursing qualifications are needed in the municipalities. The aim of the study is to explore which professional qualifications nurses need to provide emergency care in municipal emergency inpatient units. Method A qualitative design with a hermeneutic approach was employed. Interviewing physicians about nursing qualifications may be considered inappropriate. We believe that this is important for developing knowledge that can strengthen interprofessional cooperation in emergency situations. Three focus groups were conducted. Physicians with experience in municipal emergency inpatient units were interviewed. Results We synthesised three themes from the data: (1) broad medical knowledge; (2) advanced clinical skills; and (3) ethical qualifications and a holistic approach. The first theme is about knowledge, the second is about skills, and the third conveys the need for overall competence. Conclusions Nurses working in municipal emergency inpatient units need advanced ethical qualifications, which integrate broad medical knowledge, advanced clinical skills and the ability to take a holistic approach. They have a considerable responsibility to work independently and safely in a setting where both the patient and the patient’s family play important roles. Establishing arenas for collaborative practice between physicians and nurses on clinical issues may be a way of strengthening patient safety and nurses’ clinical judgement.

To explore how patients in areas without local percutaneous coronary intervention (PCI) facilities experience patient participation in different phases of the myocardial infarction pathway.Acute treatment of myocardial infarction often involves PCI. In Norway, this treatment is centralized at certain hospitals; thus, patients often require long-distance transportation and experience frequent hospital transfers. Short hospital stays, transfers between hospitals and the patient's emotional state pose challenges to promoting patient participation.A qualitative design with a narrative approach.Participants were recruited through purposive sampling. Eight men and two women were interviewed in 2016.Four themes related to the patients' experiences at the beginning, middle and end of the pathway were identified: (a) Lack of verbal communication in the acute phase; (b) trust in healthcare professionals and treatment; (c) lack of participation and coordination at discharge; and (d) shared decision-making in rehabilitation. The findings showed how the patients moved from a low level of patient participation in the acute phase to a high level of patient participation in the rehabilitation phase.This is the first study to explore patient participation in different phases of the myocardial infarction pathway. We argue that individual plans for information and patient participation are important to improve patient involvement in an earlier stage of the pathway. Further research from a healthcare professional perspective can be valuable to understand this topic.This study gives new insight that can be valuable for healthcare professionals in implementing patient participation throughout the pathway.目的: 探讨没有局部经皮冠状动脉介入治疗设施的地区的患者在心肌梗死过程不同阶段的参与情况。 背景: 急性心肌梗死的治疗通常包括皮冠状动脉介入治疗。在挪威,这种治疗集中在某些医院;因此,患者往往需要长途交通,并经历频繁的医院转诊。短时间的住院、医院间的转诊和病人的情绪状态对促进病人参与带来了挑战。 设计: 定性设计与叙述方法 方法: 参与者是通过有目的的抽样招募的。2016年,共有8名男性和2名女性接受了采访。 研究结果: 确定了患者在过程开始、中间和结束时的经历相关的四个主题:(a)急性期缺乏口头交流;(b)信任保健专业人员和治疗;(c)出院时缺乏参与和协调;(d)在康复方面的共同决策。 研究结果显示了患者如何从急性期的低水平患者参与转变为康复期的高水平患者参与。 结论: 这是第一个探索心肌梗死过程不同阶段患者参与的研究。我们认为,个人的信息计划和患者的参与对提高患者在路径早期阶段的参与很重要。从卫生保健专业人员的角度进行进一步的研究,有助于理解这一主题。 影响: 这项研究提供了新的见解,对于医疗保健专业人员实施全程患者参与具有重要价值。.

Background For individuals in need of dialysis, patient participation is important when determining care goals and in decision making regarding dialysis modality. Nephrologists hold a key role in delivering evidence-based healthcare that integrates patient preferences and values throughout the trajectory, and their experiences with patient participation are important for improving health care. The aim of this study was to explore nephrologists’ experiences with patient participation in different phases of the end-stage renal disease trajectory for working-age individuals who require dialysis. Methods This explorative study comprised interviews with ten nephrologists from four different dialysis units in Central Norway. We analysed the interviews by applying an interpretive phenomenological approach. Results Nephrologists had varied experiences with patient participation throughout the different phases of the treatment trajectory. During decision making on the dialysis modality, nephrologists emphasised patients’ choices in two approaches. In the first approach, they expected patients to choose the modality based on the provided information, which could be actively steered. In the second approach, they recognised the patients’ values and lifestyle preferences through shared decision-making. Within hospital haemodialysis, nephrologists considered patients’ self-care activities equivalent to patient participation, seeing self-care as a source of patient empowerment. They identified divergent patient–professional values and organisational structures as barriers to patient participation. Conclusion Our study shows that nephrologists have different approaches to patient participation in different phases of the end-stage renal disease trajectory. Individual understanding as well as organisational structures are important factors to address to increase patient participation in end-stage renal disease care. Shared decision making, in which patient values are balanced against biomedical treatment targets, allows for mutual agreement between patients and healthcare professionals concerning medical plans and minimises the potential for patient–professional tensions.

© 2020 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd Aim and objective: To explore how working-age adults experience patient participation in hospital haemodialysis. Background: End-stage kidney disease is a progressive, chronic condition imposing patients with high treatment burdens and low health-related quality of life. Patients face multiple medical decisions related to living with kidney failure. Given their frequent interaction with health services, patient participation may be of special value. Design: Qualitative design with a narrative approach. Methods: In 2018, eleven patients aged 35–64 years undergoing hospital haemodialysis participated in individual interviews. All interviews were analysed using a narrative approach. Reporting followed the Consolidated criteria for Reporting Qualitative Research guidelines. Findings: The patients’ narratives of participation comprised three themes following their healthcare trajectory: Informed, but not involved in treatment choices; Duality of care and control; and Frail trust reflecting collaborative deficiencies. The patients received good information about dialysis, but were not involved in choice of treatment modality. Professional work, as well as the nature of treatment, contributed to restricted patient autonomy. Patients’ trust suffered from collaborative deficiency generating delays in their treatment trajectories, and patients extended their responsibility into the coordination of transitions as a way of coping with these issues. Conclusions: The study identified challenges related to patient involvement and interdisciplinary collaboration. Involving patients through dialogue and acknowledging their experiences, preferences and lifestyles may strengthen the mutual patient–professional understanding of treatment. Despite increased focus on seamless trajectories, patients face obstacles regarding interdisciplinary collaboration and coordination of health services. Relevance to clinical practice: The findings indicate a want of individually customised care for people requiring dialysis. Patients need to be involved in the choice of treatment modality as well as decisions related to the current treatment. Information must include potential consequences of the different treatment modalities. Health services need to strengthen collaboration in order to secure treatment continuity and patient involvement.

In this study, we demonstrate how perceptions of nursing are constructed in close connection with the development of the Nordic welfare states. Drawing on Gillian Rose's framework for analysing the social and political implications of visual materials, we analysed selected visual representations of nursing published in Danish and Norwegian professional nursing journals in the period 1965 to 2016. The analyses were conducted in an iterative process in three phases. First, we reviewed all visuals spanning the entire period to obtain an overview of developmental trends in the material. Second, selected visuals and associated captions were subjected to more thorough analysis. Third, we further examined and discussed the visuals in light of societal and political movements and ideologies in Danish and Norwegian healthcare policies over this period. Our analysis shows that visual representations of the nurse–patient relationship and of the patient's and the nurse's roles and responsibilities changed over this period and that the visualisations corresponded with and supported developments in the Danish and Norwegian welfare states as these first consolidated and then moved towards individualisation and the competition state. Our study demonstrates that nurses in these states are political actors implementing health policies embedded in various knowledge regimes.

Aim To explore nurses' perceptions of patient participation in different phases of the myocardial infarction pathway. Design Qualitative design with a hermeneutical approach. Methods Five focus groups were conducted at two hospitals, one with and one without percutaneous coronary intervention facilities, between February–November 2018. Participants were recruited through purposive sampling. Twenty‐two nurses experienced in cardiac care participated. The analysis had a hermeneutical approach. Results The findings revealed nurses' perceptions of patient participation in different phases of the myocardial infarction pathway. Four themes were identified: (a) variation between paternalism and autonomy in the acute phase; (b) individualization of dialogue and patient participation during treatment; (c) lack of coherence in the pathway hinders patient participation at discharge; and (d) cardiac rehabilitation promotes patients' autonomous decisions in lifestyle changes. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

PURPOSE: Research has shown that surgery gives patients with lumbar spinal stenosis health advantages compared to conservative treatment. This qualitative study aimed to investigate the perception of symptoms from lumbar spinal stenosis by patients, and their experiences after surgery. The purpose was to create a comprehensive understanding of patients’ experiences before and after treatment. METHOD: We chose purposive sampling and conducted ten semi-structured interviews in early 2018. Thematic analysis was adopted. RESULTS: The patients stated that a strong and constant pain characterized their life situation before the operation. After surgery, the patients experienced rapid recovery from pain. The patients stated that the pain had led to considerable functional limitations. After surgery, they experienced remarkable improvement on a functional level. The patients shared their experience about how pain had prevented them from participating in meaningful activities and tasks. Some of the patients said that they had experienced depression due to the difficult situation before surgery. The patients found that treatment led to an improvement in their quality of life. CONCLUSION: The study showed that the patients who lived with severe symptoms of lumbar spinal stenosis experienced a decline in their quality in life. The condition prevented them from participating in daily activities. After surgery, they were able to participate in meaningful activities and tasks. They felt an increased participation in society. Social support and information from health care providers enables patients to make knowlege-based choises.

Aim To develop knowledge of nurses’ perceptions of participation for patients treated with haemodialysis and their next of kin. Design A qualitative study with a hermeneutic approach. Methods The data were collected in 2015 through focus groups with 13 nurses in Central Norway. Results The nurses reported that patient participation ranging from non‐involvement to shared decision‐making was related to whether dialysis was initiated as acute or scheduled. The restrictions required in chronic haemodialysis limited participation. The next of kin were not involved. The nurses highlighted interventions on both the individual and system levels to strengthen participation. Conclusion Dialysis units should develop strategies for participation related to individual needs and design treatment in cooperation with patients and their families, ensuring involvement early in the clinical pathway. Further research is needed on issues related to next of kin, including their desired level of involvement. © 2019 The Authors. Nursing Open published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Aims and objectives The objective of this study was to investigate how patient education in a surgical department was experienced by patients who had undergone total knee arthroplasty or total hip arthroplasty. Background Total knee arthroplasty and total hip arthroplasty are two of the most common and clinically effective surgical treatments performed in the Western world. Patient education efforts related to these procedures have been studied, but usually only to evaluate clinical outcome and little in a patient perspective. Design The empirics consist of qualitative in-depth interviews with 11 patients admitted to the surgical department at a Norwegian hospital. The interviews were carried out in 2011. Methods The study has a qualitative design with a phenomenological approach. The data have been analysed through meaning condensation, in accordance with Amadeo Giorgi's four-step method. N = 11. Results The education programme made the patients feel mentally prepared for surgery and the postsurgical situation. Three themes were identified: (1) realistic information preparing for surgery, (2) involvement and sense of control and (3) trust in staff. Conclusion A relationship seems to exist between how informed patients feel and how much they trust the department in which they are undergoing treatment. There may also be a relationship between a sense of control and trust. Relevance to clinical practice To build a trustful relationship between healthcare providers and patients, patient education both in groups and individually should be implemented, and be designed in a way that supports trust. Information should be realistic and accurate.

Health services in Norway have been described as fragmented with weak coordination between different care levels with respect to patient pathways. The Coordination Reform’s aim was to improve patient pathways and strengthen user participation. The aim of this study was to investigate health personnel ́s experiences with patient pathways in municipalities in Western Norway. A qualitative design was chosen. Six focus group interviews with health personnel working in municipalities in Western Norway were conducted in 2013 and 2014. The interviews revealed that health personnel experienced that local health services gave cohesive patient pathways and strengthened user participation. Cohesive patient pathways and locally adapted pathways were considered important. Coordination and electronic communication between primary and specialist health care services were seen as inadequate. Trust, teamwork, competence and necessary resources were considered vital. Health personnel ́s experiences indicated that the intended aim of cohesive patient pathways near the patient was met. © 2016 The author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

BACKGROUND Providing better and more cost-efficient health services is a goal for health policy. It is seen as desirable to provide health services close to the patient's home. From 2016, all municipalities must provide emergency hospitalisation (EH). The objective of this study was to develop experience-based knowledge from medium-sized municipalities that operate such services without any inter-municipal collaboration. MATERIAL AND METHOD Focus-group interviews with 25 health workers who are responsible for this service in six small and medium-sized municipalities in Western Norway were conducted in the autumn of 2013 and the spring of 2014. Additional information on bed utilisation was also collected. RESULTS The informants reported that their municipalities had chosen emergency hospitalisation as a measure to reinforce the professional communities in the nursing homes. They described this as a patient-centred and flexible treatment option. In their opinion, the programme would help ensure competence enhancement in the municipalities. Bed utilisation increased from the introduction of EH until 31 August 2014. INTERPRETATION The health workers reported that emergency hospitalisation in the municipality fulfilled key intentions of the Interaction Reform, in terms of providing treatment to patients locally and close to their homes.

The aim was to gain insight into how patients with advanced chronic obstructive pulmonary disease (COPD) experience care in the acute phase. The study has a qualitative design with a phenomenological approach. The empirics consist of qualitative in-depth interviews with ten patients admitted to the intensive care units in two Norwegian hospitals. The interviews were carried out from November 2009 to June 2011. The data have been analysed through meaning condensation, in accordance with Amadeo Giorgi's four-step method. Kari Martinsen's phenomenological philosophy of nursing has inspired the study. An essential structure of the patients' experiences of care in the intensive care unit by acute COPD-exacerbation may be described as: Feelings of being trapped in a life-threatening situation in which the care system assumes control over their lives. This experience is conditioned not only by the medical treatment, but also by the entire interaction with the caregivers. The essence of the phenomenon is presented through three themes which describe the patient's lived experience: preserving the breath of life, vulnerable interactions and opportunities for better health. Acute COPD-exacerbation is a traumatic experience and the patients become particularly vulnerable when they depend on others for breathing support. The phenomenological analysis shows that the patients experience good care during breath of life preservation when the care is performed in a way that gives patients more insight into their illness and gives new opportunities for the future.

Aim To report a study conducted to explore intensive care unit nurses’ perceptions of patient participation in the acute phase of chronic obstructive pulmonary disease exacerbation. Background An acute exacerbation is a life-threatening situation, which patients often consider to be extremely frightening. Healthcare personnel exercise considerable power in this situation, which challenges general professional notions of patient participation. Design Critical discourse analysis. Methods In the autumn of 2009, three focus group interviews with experienced intensive care nurses were conducted at two hospitals in western Norway. Two groups had six participants each, and one group had five (N = 17). The transcribed interviews were analysed by means of critical discourse analysis. Findings The intensive care nurses said that an exacerbation is often an extreme situation in which healthcare personnel are exercising a high degree of control and power over patients. Patient participation during exacerbation often takes the form of non-involvement. The participating nurses attached great importance to taking a sensitive approach when meeting patients. The nurses experienced challenging ethical dilemmas. Conclusion This study shows that patient participation should not be understood in universal terms, but rather in relation to a specific setting and the interactions that occur in this setting. Healthcare personnel must develop skill, understanding, and competence to meet these challenging ethical dilemmas. A collaborative inter-professional approach between physicians and nurses is needed to meet the patients’ demand for involvement.

Background:Several Norwegian local authorities have established positions for cancer nurses, but we have little knowledge of what functions they have and what expertise they provide.Aim:The purpose of this study was to get more knowledge about what functions cancer nurses have in their local communities and how they experience and assess their professional role.Methods:Information was collected through research interviews with eight cancer nurses.Findings:The cancer nurses expressed that they had both patient-oriented and system-oriented functions. Central, patient-oriented functions covered almost anything from assessing patient condition, treatment, alleviate pain and symptoms, patient care, and information and counselling to patients and their next of kin. One of the most important system-oriented functions was the coordination of various health services. Some experienced that documenting the way working hours had been used was a task that had to be done after working hours. Others had experienced a hi...

The aim of this study is to explore how nurses perceive patient participations of patients over 75 years old undergoing hemodialysis treatment in dialysis units, and of their next of kin. Ten nurses told stories about what happened in the dialysis units. These stories were analyzed with critical discourse analysis. Three discursive practices are found: (1) the nurses’ power and control; (2) sharing power with the patient; and (3) transferring power to the next of kin. The first and the predominant discursive practice can be explained with an ideology of paternalism, in which the nurses used biomedical explanations and the ethical principle of benefice to justify their actions. The second can be explained with an ideology of participation, in which the nurses used ethical narratives as a way to let the patients participate in the treatment. The third seemed to involve autonomous decision-making and the ethical principle of autonomy for the next of kin in the difficult end-of-life decisions.

aasen e.m., kvangarsnes m., wold b. & heggen k. (2011) The next of kin of older people undergoing haemodialysis: a discursive perspective on perceptions of participation. Journal of Advanced Nursing68(6), 1716–1725. Abstract Aim. This paper is a report of a study conducted to explore how the family members of older people who will undergo haemodialysis treatment for the rest of their lives perceive participation. Background. The rights of families to participate in treatment and health care are supported by international law, and by national law in Norway since 1999. Method. This study, which employed an explorative qualitative approach, was carried out in Norway in 2008. Data were derived from transcribed interviews with seven family members underwent critical discourse analysis. Findings. Three discourse practices about the next of kin perception of participation were found: (1) to care and take control, (2) to struggle for involvement, and (3) to be forgotten and powerless. The next of kin said that they had no dialogue with the healthcare team, and some fought to be included in the decision-making process. Conclusion. The dominant part of the discourse as expressed by the next of kin seems to be a paternalistic ideology. Thus, finding ways to enable the next of kin to participate in the decision-making process seems to be a major challenge for the healthcare team in the dialysis units.

Scand J Caring Sci; 2012; 26; 61–69 Perceptions of patient participation amongst elderly patients with end-stage renal disease in a dialysis unit Aim: A patient’s right to influence treatment and health care has been guaranteed by Norwegian law since 1999. The aim of this study was to explore how elderly patients with end-stage renal disease who are undergoing treatment with haemodialysis for the rest of their lives perceive patient participation in a dialysis unit. Methods: This study, which was inspired by critical discourse analysis, drew on data derived from transcribed interviews with 11 patients. Findings: Two discourses related to patient participation were identified. The first and dominant discourse was called the health-care team’s power and dominance. Both environmental conditions and the team’s practice exercised power and control over the patients. The patients trusted the health-care team, but some felt powerless and were afraid of what might happen if they refused to follow the instructions. The health-care team owned the knowledge and decided what the patients needed to know. Most of all the patients wanted dialogue about the future. After years of treatment, patient identity seemed to be threatened by this situation. The second discourse is called the patients struggling for shared decision-making. Some patients struggled to be involved in decision-making about ‘dry weight’, diet, blood access and time of treatment when these factors threatened their well-being and the quality of their daily lives. Conclusions: The elderly patients’ right to participate in their haemodialysis treatment did not seem to be well incorporated into the social practices of haemodialysis units. Changing the social practices in the dialysis units from a paternalistic ideology to an ideology of participation will require consideration of the context, the dialogue and the process of shared decision-making with the patient.

Aims and objectives To investigate the tension between individual and organisational responses to contemporary demands for compassionate interactions in health care. Background Health care is often said to need more compassion among its practitioners. However, this represents a rather simplistic view of the issue, situating the problem with individual practitioners rather than focusing on the overall design of care and healthcare organisations, which have often adopted a production-line approach. Design This is a position paper informed by a narrative literature review. Methods A search of the PubMed, Science Direct and CINAHL databases for the terms compassion, care and design was conducted in the research literature published from 2000 through to mid-2013. Results There is a relatively large literature on compassion in health care, where authors discuss the value of imbuing a variety of aspects of health services with compassion including nurses, other practitioners and, ultimately, among patients. This contrasts with the rather limited attention that compassionate practice has received in healthcare curricula and the lack of attention to how compassion is informed by organisational structures and processes. We discuss how making the clinic more welcoming for patients and promoting bidirectional compassion and compassion formation in nursing education can be part of an overall approach to the design of compassionate care. Conclusions We discuss a number of ways in which compassion can be enhanced through training, educational and organisational design, through exploiting the potential of brief opportunities for communication and through initiatives involving patients and service users, as well as practitioners and service leaders. Relevance to clinical practice The development of contemporary healthcare systems could usefully address the overall design of compassionate care rather than blame individual practitioners for a lack of compassion.

AIMS AND OBJECTIVES: To explore patient perceptions of chronic obstructive pulmonary disease exacerbation and the patients' experiences of their relations with health personnel during care and treatment. BACKGROUND: Patients suffering from acute exacerbation of chronic obstructive pulmonary disease often experience life-threatening situations and undergo noninvasive positive-pressure ventilation via bi-level positive airway pressure in a hospital setting. Theory on trust, which often overlaps with the issue of power, can shed light on patient's experiences during an acute exacerbation. DESIGN: Narrative research design was chosen. METHODS: Ten in-depth qualitative interviews (n = 10) were conducted with patients who had been admitted to two intensive care units in Western Norway during the autumn of 2009 and the spring of 2010. Narrative analysis and theories on trust and power were used to analyse the interviews. RESULTS: Because of their breathlessness, the patients perceived that they were completely dependent on others during the acute phase. Some stated that they had experienced an altered perception of reality and had not understood how serious their situation was. Although the patients trusted the health personnel in helping them breathe, they also told stories about care deficiencies and situations in which they felt neglected. CONCLUSIONS: This study shows that patients with an acute exacerbation of chronic obstructive pulmonary disease often feel wholly dependent on health personnel during the exacerbation and, as a result, experience extreme vulnerability. RELEVANCE TO CLINICAL PRACTICE: The findings give nurses insight into building trust and a good relationship between patient and caregiver during an acute exacerbation of chronic obstructive lung disease.

The aim of the study was to gain insight into intensive care nurses’ perspectives on compassionate care for patients with exacerbated chronic obstructive pulmonary disease. Patients who experience acute exacerbation are vulnerable because they experience a life-threatening situation and are wholly dependent on health-care interventions to relieve breathlessness. A hermeneutic phenomenological approach was used. Three focus group interviews with intensive-care nurses were conducted at two hospitals in western Norway in the autumn of 2009. One group had five participants, and two groups had six participants each (N=17). A collaborative practice was regarded as essential to provide compassionate care in these situations. Three main themes emerged from the data: (a) preparing to care for breathlessness; (b) establishing a trusting relationship; (c) to approach each patient as a person with unique needs. These were experienced as important in rendering compassionate care for patients with exacerbation of chronic obstructive pulmonary disease. The study showed that compassionate care involves interventions at different levels with particular attention to simple comforting care and technical adjustments. The study also showed a need for enhanced multidisciplinary cooperation in planning the subsequent clinical pathway.

A patient's right to influence treatment and health care has been guaranteed by Norwegian law since 1999. The aim of this study was to explore how elderly patients with end-stage renal disease who are undergoing treatment with haemodialysis for the rest of their lives perceive patient participation in a dialysis unit.This study, which was inspired by critical discourse analysis, drew on data derived from transcribed interviews with 11 patients.Two discourses related to patient participation were identified. The first and dominant discourse was called the health-care team's power and dominance. Both environmental conditions and the team's practice exercised power and control over the patients. The patients trusted the health-care team, but some felt powerless and were afraid of what might happen if they refused to follow the instructions. The health-care team owned the knowledge and decided what the patients needed to know. Most of all the patients wanted dialogue about the future. After years of treatment, patient identity seemed to be threatened by this situation. The second discourse is called the patients struggling for shared decision-making. Some patients struggled to be involved in decision-making about 'dry weight', diet, blood access and time of treatment when these factors threatened their well-being and the quality of their daily lives.The elderly patients' right to participate in their haemodialysis treatment did not seem to be well incorporated into the social practices of haemodialysis units. Changing the social practices in the dialysis units from a paternalistic ideology to an ideology of participation will require consideration of the context, the dialogue and the process of shared decision-making with the patient.

Learning and competence development in community health service – an interview study of cancer nurses The number of cancer patients is expected to increase 30% by 2020. To meet the needs of seriously ill and dying cancer patients the community health service must be strengthened. There is little knowledge about the development of competence in the community health service. The aim of this study was to get more knowledge about competence development of cancer nurses.The study has a phenomenological hermeneutical design. Data was based on eight qualitative interviews with cancer nurses. The content of daily work and the cooperation within the community of practice were found to be important. Experience, theoretical knowledge, expectations and attitudes were of importance in their learning, and this is accomplished in cooperation with others through trust, having enough time and responsibility. It will be a challenge to meet the demands to quality and competence in future cancer care. Employing advanced nurse practitioners can be a resource, strengthening quality, improving nursing and innovation. Dette tidsskriftet gir umiddelbar og fri tilgang (Open Access) til innhold, ut fra det prinsipp at det å gjøre forskning fritt tilgjengelig for allmennheten gir økt global utveksling av kunnskap. Tidsskriftet krever ingen forfatterbetaling ("article processing charges", "article submission charges").