Lena Nyholm

Aim: To explore person‐centred care in surgical inpatient settings by examining the person‐centred climate alongside patients' experiences of the fulfilment of fundamental care needs. Design: A convergent parallel mixed methods design. Methods: Surgical inpatients ( n = 26) completed the Person‐centred Climate Questionnaire–Patient version and participated in structured interviews, comprising binary questions with open‐ended elaborations. Quantitative and qualitative data were analysed separately and thereafter brought together through an integrated interpretation of the findings. Results: Questionnaire scores indicated a person‐centred climate. Interview findings showed that patients described staff as kind, present, and compassionate, while also reporting several unmet fundamental care needs related to information, participation, hygiene, toileting, and symptom management. The integrated findings showed that patients reported a person‐centred climate while simultaneously describing shortcomings in the delivery of fundamental care. Conclusion: These findings highlight that global assessments of person‐centred climate may overlook deficiencies in fundamental care and underscore the importance of considering multiple dimensions when evaluating person‐centred care in clinical practice. Implications for the Profession and/or Patient Care: Assessing person‐centred care requires attention to both the care climate and the extent to which patients' fundamental care needs are met. Combining structured measures with opportunities for patients to describe their care experiences may improve the identification of unmet needs and inform efforts to strengthen person‐centred care in practice. Impact: The study illustrates that being treated with kindness and goodwill does not necessarily ensure high‐quality person‐centred care. The findings are relevant for clinicians, nurse leaders, and researchers and support the use of multi‐method approaches when evaluating person‐centred care. Reporting Method: The quantitative and qualitative content in this study is reported in accordance with the relevant STROBE guidelines. Patient or Public Contribution: The project is part of a research program developed in collaboration with the nurses and nursing leaders at the care units. What Does This Paper Contribute to the Wider Global Clinical Community?: The findings highlight the importance of combining different approaches when evaluating person‐centred care. Asking about concrete care situations and experiences may help reveal unmet fundamental care needs that might otherwise remain hidden in survey responses.

Aims: To explore challenges involved in designing and conducting qualitative interviews with people with communication impairment due to acquired brain injury, as well as analysing data from such interviews, and to map strategies used to facilitate participation. Design: Secondary analysis of qualitative interview data. Methods: A secondary qualitative content analysis was conducted using data from a previous multiple‐case interview study on daily life without cranial bone protection. Data comprised interviews with patients with acute severe brain injury, family members and staff, as well as logbook notes and field notes incorporated into transcripts. Results: Findings are presented as a timeline and thematic categories, highlighting challenges related to planning, interviewing people with communication impairment, and interpreting fragmented or partly non‐verbal narratives. Strategies included flexible interview procedures, the use of logbooks for planning and analysis, and field notes to capture non‐verbal cues. Involvement of family members facilitated participation and interpretation. Conclusion: Despite challenges throughout planning, interviewing, and analysis, individuals with communication impairment due to acquired brain injury contributed valuable insights. Involving persons close to the patient enriched and confirmed patient narratives, while direct questioning and documentation of non‐verbal communication added depth and breadth that could not be gathered from other sources. Implications for the Profession and/or Patient Care: The findings provide practical guidance for researchers and clinicians seeking to include people with communication impairment in qualitative research. Impact: What problem did the study address? People with communication impairment after acquired brain injury are often excluded from qualitative interview research. What were the main findings? Meaningful participation was facilitated through flexible interviewing, communication support, field notes, and involvement of family members. Where and on whom will the research have an impact? The findings may support researchers and clinicians working with people with communication impairment following acquired brain injury. Reporting Method: COREQ. Patient or Public Contribution: No Patient or Public Contribution.

Aim: To identify illegitimate tasks performed by registered nurses (RNs) in surgical care and explore why they perform them through the lens of gender theory and nursing history. Design: A qualitative study guided by gender theory, nursing history and the Fundamentals of Care framework. Methods: RNs ( n = 48) at three surgical wards attended a lecture on gender theory and a lecture on nursing history, each followed by focus group interviews ( n = 12) with 6–8 participants. The analysis included two steps: (A) a content analysis of the interviews to identify illegitimate tasks and (B) a gender analysis using Connell's framework and nursing history. Results: The RNs describe their work situation in clinical practice as fragmented by illegitimate tasks. The results show how this can be explained as induced by gender theory and nursing history, with the main theme RNs support overall patient care and work climate at the cost of nursing care—a behaviour explained by gender theory and nursing history, presented in four categories: (1) performing administrative tasks and information processing outside the nursing profession, (2) maintaining a pleasant workplace, (3) being constantly available, facilitating and compensating for physicians and (4) backing up nursing assistants. Conclusion: Contemporary RNs frequently utilise their resources to carry out a wide range of illegitimate tasks. The findings illustrate that RNs remain influenced by their history and still integrate traditionally female‐associated tasks and behaviours into the workplace, often without conscious awareness. This knowledge can be used to understand why RNs perform illegitimate tasks without being asked to do so. Primarily, managers and also RNs must consider their complex situation from this perspective to implement systematic organisational changes that ensure patients receive the nursing care they need. Impact: There is a global shortage of registered nurses (RNs). Patients suffer from missed nursing care. RNs describe their work as fragmented, with frequent interruptions and illegitimate tasks they feel expected to prioritise, even if not prompted by routines or requests. RNs are influenced by nursing history, integrating traditionally female‐associated tasks and behaviours into the workplace, often subconsciously. When nurse managers and RNs become aware of these problems, it can pave the way for change, which can free up nursing resources and improve patient care. By becoming aware of what constitutes illegitimate tasks and understanding why nurses perform them, organisational changes can be made to fully utilise RNs' competencies. The findings point to a systemic issue that calls for strategic leadership from managers to drive substantive change.

Aim: To describe how the Fundamentals of Care framework was applied within a postgraduate nursing programme facilitated by a pedagogical project for educators. Design: A discursive paper approach was used. Data Sources: The paper draws on the authors' experiences from a pedagogical project that included a book circle, an education retreat, and a mini‐conference and identified learning activities applied in the programme. Findings: The Fundamentals of Care framework was integrated into learning activities, such as assignments, seminars, and exams, within a diversity of specialties: anaesthesia, intensive care, emergency care, operation theatre, psychiatric care, prehospital care, and surgical care. In this paper, we provide an overview and examples of how the learning activities were applied. Conclusion: This pedagogical project in a post‐graduate nursing programme illustrated that the Fundamentals of Care framework is applicable to learning activities in education at the post‐graduate level. Application of the framework at the post‐graduate level could facilitate students' understanding of the importance of fundamental care for patients with complex care needs requiring advanced nursing interventions. It can also help students understand how to use theory in clinical practice. However, further research could focus on conducting interviews with students to understand their experiences and whether their views on nursing have changed.

It is well‐known that the implementation of evidence into clinical practice is complex and challenging. The integrated Promoting Action on Research Implementation in Health Services (i‐PARIHS) framework conceptualizes successful implementation of evidence into practice. As the implementation of the mentoring programme proved to be a challenge, it seemed valuable to retrospectively study the implementation process using a framework like the i‐PARIHS. Aim: The aim of this study was to evaluate implementation of a multifaceted mentoring programme for bedside nurses using the i‐PARIHS framework, to identify factors that influenced the implementation. Design: A secondary analysis of qualitative data using the i‐PARIHS framework as the theoretical lens. Method: A directed content analysis was performed, driven theoretically by the i‐PARIHS framework. The analysis focused separately on (a) characteristics of the innovation and (b) successful and hindering factors in the implementation process. Results: The results showed that successful factors influencing implementation of the mentoring programme included supportive and actively involved formal leaders and supervisors at the unit level. A major hindering factor was lack of resources in the form of personnel, time and money. A lack of facilitators, particularly experienced facilitators, throughout the organization hindered implementation. The i‐PARIHS framework offered a structured how‐to guide to identify factors that influenced the implementation process. Conclusion: Implementation of the mentoring programme was a challenge for the organization. Investment into implementation should continue, with a more structured facilitation process. A structured and prioritized management system, including supportive leadership at the unit level, should be established by the hospital board. Implications for the profession: There is a need for experienced facilitators throughout the organization. This is crucial to achieve sustainability in the mentoring programme and ensure that the large investments of staff resources and money do not fizzle out. Impact: What problem did the study address?: Implementing a mentoring programme for nurses in a large university hospital proved to be a challenge. Therefore, it seemed valuable to retrospectively study the implementation process using a framework like the i‐PARIHS. What were the main findings?: A lack of facilitators, particularly experienced facilitators, throughout the organization hindered the implementation. The i‐PARIHS framework offered a structured how‐to guide to identify factors that influenced the implementation process. Where and on whom will the research have an impact?: Our findings are important for leaders on all levels in a hospital setting, including the hospital board, heads of departments and nurse managers. Reporting Method: Consolidated criteria for reporting qualitative research (COREQ): a 32‐item checklist for interviews and focus groups is used. Patient or Public Contribution: No patient or public contribution.

Background: Severely brain injured patients treated in the neuro intensive care unit (NICU) are usually sedated. Sedation may affect not only the ability to sleep, but also the EEG rhythms used to identify sleep. Aim: The aims were: To study if sleep patterns could be identified in the severely brain injured and sedated patients in the NICU To study if sleep patterns could be identified in patients the night after brain tumor surgery in the neurointermediate care unit (NIMCU) To search for risk factors for not being able to sleep after brain tumor surgery Study design: Two populations were included; one with patients affected by severe brain injury and one with patients who had undergone planned brain tumor surgery. This was a quantitative observational study using EEG. Eligible neurointensive care patients for this study had to be suffering from a neurosurgical condition (for example subarachnoid haemorrhage, acute subdural hematoma, intracerebral haemorrhage and meningitis), have affected consciousness and age over 18 years. Thirty-seven patients were included from NICU. Ninety-eight patients, with a suspected glioma (WHO grade II-IV) planned for surgery were also included. Results: Neuro intensive care patients, sedated and treated in ventilator, showed no EEG sleep patterns at all. After brain tumor surgery, sleep occurred in 74% of the patients, despite frequent wake-up tests. The patients with sleep patterns were on average 8 years younger, p = 0.03. Conclusions: Patients with severe brain injury are at risk of having no sleep when treated at the NICU, whereas after brain tumor surgery, sleep occurs in three-fourths of the patients. Further studies and new methods are warranted to identify sleep and investigate how the loss of sleep affects these patients and how sleep disturbances can be managed.

Critical care is complex and stressful. It is difficult to register in real time data not recorded by automatic systems. Time-specific knowledge of manual measures is important for understanding pathophysiology and for analyzing treatment and quality of care. Therefore, a novel iPad-based method for registration of manual measures was developed, which many can build themselves. Using a configuration for intracranial pressure (ICP) management, the methodology was validated, ICP treatment captured, and the quality of ICP management evaluated. Twenty-two patients with acute brain injuries were studied. The iPad-system was totally used for 2538 h. Thirteen-hundred-five manual measures were entered. Thirty-nine episodes of predefined ICP insults were identified. During 16/39 episodes, ICP treatments were registered. For 4/39 episodes treatments were registered within 90 s before or after the episode. For 3/39 episodes it was registered that treatment was intentionally refrained. In 15/16 episodes without registered treatment, the insult was mild or reasonable explanations were found when medical records and the Patient data management system were reviewed. In one situation without particular circumstances, morphine and clonidine were given to decrease ICP but not registered. No episodes of downtime or loss of data occurred. The developed methodology appears to be stable and robust as well as feasible and user-friendly. It was possible to capture the treatment of ICP insults with high temporal resolution, and to evaluate the quality of ICP management. An own developed novel tablet-based system like our system may be a promising potential tool useful in various future intensive care applications.

Background: Many patients with neurological insults requiring neurointensive care have an increased risk of acute symptomatic seizures. Various nursing interventions performed when caring for these patients may elicit pathological cerebral electrical activity including seizures and stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs). The aim was to explore changes in electroencephalogram (EEG) due to neurointensive care nursing interventions. Methods: A convenience sample was recruited between November 2015 and April 2016, consisting of 12 adult patients with impaired consciousness due to a neurosurgical condition. Continuous EEG and simultaneous video recordings of nursing interventions were collected 48 continuous hours for each patient. Two analysts categorized the video recordings for common nursing interventions, and a neurophysiologist analyzed the EEGs. Results: In total, 976 nursing interventions were observed. Epileptiform activity was observed in 4 patients (33%), during 1 nursing intervention episode each (0.4%). The 4 observed episodes of epileptiform activity occurred during multiple simultaneous nursing interventions (n = 3) and hygienic interventions (n = 1). Stimulus-induced rhythmic, periodic, or ictal discharges were observed in 1 patient (8%), in 1 single nursing intervention (0.1%). The observed SIRPIDs occurred during repositioning of the patient. All patients had muscle artifacts, during 353 nursing interventions (36.3%). The duration of nursing interventions was longer for those with simultaneous muscle artifacts (median, 116 seconds) than those without muscle artifacts, epileptiform activity, or SIRPIDs (median, 89.0 seconds). With regard to epileptiform activity and SIRPIDs, the median durations of the nursing interventions were 1158 and 289 seconds, respectively. Conclusion: The results of this pilot study indicate that muscle artifacts seem prevalent during nursing interventions and may be a sign of stress. Nurses should be aware of the risk of inducing stress by performing regular nursing interventions in daily practice, consider shorter or fewer interventions at a time in sensitive patients, and administer sedation accordingly. Considering that this was a pilot study, more research that investigates correlations between EEG patterns and nursing interventions in larger samples is needed.

Background: Hyperthermia is a common secondary insult in traumatic brain injury (TBI). The aim was to evaluate the relationship between hyperthermia and intracranial pressure (ICP), and if intracranial compliance and cerebral blood flow (CBF) pressure autoregulation affected that relationship. The relationships between hyperthermia and cerebral oximetry (BtipO2) and cerebral metabolism were also studied. Methods: A computerized multimodality monitoring system was used for data collection at the neurointensive care unit. Demographic and monitoring data (temperature, ICP, blood pressure, microdialysis, BtipO2) were analyzed from 87 consecutive TBI patients. ICP amplitude was used as measure of compliance, and CBF pressure autoregulation status was calculated using collected blood pressure and ICP values. Mixed models and comparison between groups were used. Results: The influence of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and BtipO2) was small, but individual differences were seen. Linear mixed models showed that hyperthermia raises ICP slightly more when temperature increases in the groups with low compliance and impaired CBF pressure autoregulation. There was also a tendency (not statistically significant) for increased BtipO2, and for increased pyruvate and lactate, with higher temperature, while the lactate/pyruvate ratio and glucose were stable. Conclusions: The major finding was that the effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and BtipO2) were not extensive in general, but there were exceptional cases. Hyperthermia treatment has many side effects, so it is desirable to identify cases in which hyperthermia is dangerous. Information from multimodality monitoring may be used to guide treatment in individual patients.