Ann-Therese Hedqvist

Background: Ambulance clinicians in emergency medical services (EMS) work under demanding conditions characterised by high workload, unpredictable environments, and exposure to potentially traumatic incidents. These stressors may negatively affect their health and well-being. Understanding how psychosocial work environment factors relate to health outcomes is therefore important for developing preventive strategies in prehospital emergency care. This study aimed to describe ambulance clinicians’ self-rated psychosocial work environment and health in northern Sweden and to examine associations between psychosocial work environment factors and health outcomes. Methods: An exploratory cross-sectional study was conducted using an anonymous web-based survey of all ambulance clinicians in one northern Swedish region (November 2024; 22 ambulances across eight service areas). Of 187 eligible participants, 134 responded (71.6%). Measures included the General Nordic Questionnaire for Psychological and Social Factors at Work subscales (role clarity, role conflict, job demands, job control, social support, organisational culture, leadership), job satisfaction, self-rated health (SRH), insomnia, exhaustion, anxiety, depression, post-traumatic stress symptoms, and cumulative exposure to traumatic incidents. Analyses included descriptive statistics, Spearman correlations, and group comparisons. Results: Most ambulance clinicians reported good SRH (83.6%). However, 19.4% screened positive for elevated anxiety, 12.7% for depressive symptoms, 8.2% for clinical insomnia, 6.7% for exhaustion, and 2.2% for probable post-traumatic stress disorder. Higher job demands and role conflict were consistently associated with greater symptom burden and lower SRH, whereas role clarity and job satisfaction showed protective associations. A more positively perceived organisational culture and stronger leadership were also associated with better health outcomes. Clinicians working at urban stations reported higher job demands and role conflict, poorer sleep, higher anxiety and posttraumatic stress, and lower SRH compared with those at rural stations. Conclusion: Psychosocial work environment factors were closely associated with ambulance clinicians’ health. High job demands and role conflict were consistently linked to poorer health outcomes, whereas role clarity, job satisfaction, supportive leadership, and a positive organisational culture were associated with more favourable health outcomes. These findings highlight organisational factors that may be relevant to consider in efforts to improve workforce health and sustainability in emergency medical services.

Introduction: Older adults are increasingly recognised as valuable contributors in health and social care research, yet their involvement as active research partners remains inconsistent and under-theorised across contexts. The aim of this study is to investigate how older adults are involved as active research partners in health and social care research and to build consensus on strategies and enabling conditions that can support and strengthen such involvement. Methods and analysis: This study uses a sequential exploratory mixed-methods design comprising three phases. In the preparatory phase, the study protocol was developed and the ethical approval application was prepared and submitted. In the exploratory phase, an umbrella review of international evidence, a mapping survey with older adults and researchers, qualitative interviews and a participatory concept-mapping workshop will be conducted to identify experiences, practices, barriers and strategies for involving older adults as research partners. The empirical components will primarily be conducted within a Swedish context to generate context-sensitive insights. Findings will be triangulated to develop a preliminary framework and candidate consensus statements. In the consensus-building phase, a modified Delphi study will be conducted with two expert panels of older adults and researchers, respectively. Across iterative rounds, participants will rate the importance and feasibility of each statement using 5-point Likert scales. Quantitative data will be analysed descriptively to assess consensus levels and qualitative comments will undergo content analysis. Results will be analysed overall and by panel to identify areas of agreement and divergence. Ethics and dissemination: The study has received an advisory opinion from the Swedish Ethical Review Authority (reference number 2025–08878-01). The study will be conducted in accordance with Swedish ethical regulations and applicable data protection legislation, including the General Data Protection Regulation. Older adults have been involved in shaping the study and corresponding protocol and will contribute to the interpretation and dissemination of findings. Results of this study will be shared through peer-reviewed publications and conference presentations.

The purpose of both precision medicine and precision nursing is to improve patient outcomes. This theoretical article is designed as a conceptual and position paper situated within caring science, with a specific focus on understanding precision nursing across diverse clinical contexts. Rather than presenting empirical findings, the paper synthesizes theoretical perspectives, caring science foundations, and selected scholarly literature. In this position paper, we seek to expand the concept of precision nursing from a caring science perspective with clinical examples, vignettes, from an emergency care context. Precision medicine can be viewed as an effort to truly individualize a treatment and make it as accurate and effective as possible. While the focus on measurable outcomes saves lives, it also carries the risk of narrowing attention to what can be observed and quantified. These visible clinical markers represent only part of what matters in care. To get the full picture of a patient and their treatment, caring must serve as the foundation for precision nursing, as it is caring that ensures that technological advancements remain aligned with individual patient needs. Precision medicine and precision nursing may offer direction, but to provide meaning to the concepts, a grounding in caring science is provided in this study.

Introduction: The involvement of older adults as active partners in research is increasingly being promoted to improve the relevance and impact of scientific knowledge. However, the evidence base on how older adults have been involved as active partners in healthcare research remains fragmented. To our knowledge, no review of reviews has yet provided a comprehensive overview of this body of evidence. Therefore, this umbrella review aims to synthesise review-level evidence on the involvement of older adults as active research partners. We address three questions: (1) How have older adults been involved as active partners in research? (2) What terminology, models and frameworks have been used? (3) What benefits and challenges have been reported related to involving older adults as active partners in research? Methods and analysis: This study will follow the Joanna Briggs Institute (JBI) methodology for umbrella reviews. A comprehensive search will be conducted in Medline, CINAHL, Scopus, PsycINFO, Sociological Abstracts and Web of Science. Eligible reviews will be those reporting on the involvement of older adults (aged 60 years or older) as active partners in research. Two reviewers will independently screen titles, abstracts and full texts and perform data extraction using a standardised form. Methodological quality will be assessed using the JBI Critical Appraisal Checklist for Systematic Reviews. Findings will be synthesised narratively and thematically, with attention to reported roles, terminology, conceptual frameworks and the benefits and challenges of involvement. Ethics and dissemination: As this umbrella review draws exclusively on secondary data from published sources, ethical approval is not required. Older adults, engaged as independent public contributors, have been involved in shaping the review protocol and will take part in interpreting the findings. Results will be disseminated through a peer-reviewed journal and presentations at academic and stakeholder conferences, and used to inform the design of a subsequent mixed-methods study focused on strengthening the involvement of older adults as active partners in research. PROSPERO registration number: CRD420251064947.

Background: Although caring is a core concept in nursing, its meaning is not uniform, and perceptions may vary across care settings. In ambulance care, encounters with older patients with complex care needs present challenges that may shape how caring is understood and practiced. Guided by a lifeworld‐led caring perspective, this study explores how caring is perceived and enacted in this specific clinical context. Aim: This study aims to describe variations in nurses' perceptions of caring in ambulance encounters with older patients with complex care needs. Methods: This qualitative study employed a phenomenographic approach to identify variations in nurses' perceptions of caring in ambulance encounters with older patients with complex needs. Semi‐structured interviews with 16 nurses in ambulance care from two regions in Sweden were analysed using a phenomenographic method. Ethical Considerations: Ethical approval was granted by the Swedish Ethical Review Authority. All participants provided informed consent to participate. Results: The outcome space comprised three qualitatively different ways in which nurses perceived caring: ‘Caring as balancing symptoms and medical care’, ‘Caring as negotiating responsibility’, and ‘Caring as responding to an ethical demand’. Conclusions: Caring in ambulance encounters with older patients with complex care needs is perceived as a multidimensional and contextually situated practice that integrates clinical, relational, and ethical dimensions. While caring was often expressed in terms of balancing symptoms and medical interventions, it also involved moral sensitivity, relational engagement, and professional responsibility. These findings contribute to a deeper understanding of caring as a lifeworld‐led and ethically grounded practice in ambulance care, with implications for education, reflective practice, and policy development.

Background: Coordinated, multidisciplinary care is essential when addressing the complex needs of an aging population, with prehospital emergency care providers often serving as a common point of contact. Addressing complex care needs while maintaining continuity of care necessitates seamless collaboration between diverse healthcare providers. Despite this, there is limited research on interprofessional collaboration in prehospital care of older patients with complex needs. Understanding what influences interprofessional collaboration and identifying areas for improvement are vital for optimizing prehospital care for this vulnerable population. This study aimed to explore ambulance clinicians' perspectives on interprofessional collaboration in prehospital emergency care for older patients with complex care needs and to identify key factors influencing collaboration. Methods: An explanatory sequential mixed-methods design was employed in this study, conducted in southern Sweden. In Phase 1, quantitative data were collected via an online survey completed by 118 ambulance clinicians (ACs). Descriptive statistics, chi-square tests, and Kruskal–Wallis tests were used to analyze the data. Qualitative responses were analyzed through inductive content analysis, informing the development of an interview guide. In Phase 2, semi-structured interviews were conducted with 20 ACs and analyzed using inductive content analysis. Findings from both phases were integrated using a joint-display matrix, combining quantitative patterns with qualitative insights for a comprehensive interpretation. Results: Quantitative findings revealed that although collaboration with patients' families and care staff was generally rated as satisfactory by ACs, significant challenges were reported in coordinating care with other healthcare actors, especially home care nurses. About 89% of respondents reported insufficient access to patient information, highlighting difficulties in retrieving such information. Qualitative data underscored the importance of comprehensive patient information for effective decision-making and alignment with patient preferences and care goals. The integrated analysis identified three key factors influencing interprofessional collaboration: defined goals of care, access to information, and clarity in roles and responsibilities. Challenges in maintaining continuity and responsiveness, particularly during night shifts, were emphasized as barriers to effective collaboration. Conclusion: Addressing deficiencies in nighttime care coordination, improving access to comprehensive patient information, and strengthening communication pathways between healthcare providers are essential steps in improving interprofessional collaboration to strengthen prehospital care of older patients with complex care needs.

Aim: The overall aim was to explore inter-organizational collaboration and adaptability in care coordination, focusing on seamless care for patients with complex care needs. Methods: This thesis employed diverse qualitative methodologies across four studies. Studies I–III used an ethnographic approach with convergent data collection techniques, including document review, participant observations, and interviews with healthcare and social care professionals. Studies I and II applied the Functional Resonance Analysis Method to explore care transitions and identify vulnerabilities. Study III constructed a grounded theory of inter-organizational collaboration from insights across healthcare and social care domains. Study IV utilized a web-based questionnaire to collect written critical incidents reported by registered nurses in ambulance care. These incidents were analyzed using Critical Incident Technique and Interpretive Description, focusing on adaptation, decision-making, and learning in ambulance care during the COVID-19 pandemic. Lastly, findings from all studies were synthesized. Findings: Seamless care for patients with complex needs depends on timing and precision in planning and information exchange across care provider boundaries. Gaps in these processes can increase vulnerabilities (I, II). Effective care coordination relies on bridging professional and organizational divides through established collaboration pathways while stretching across organizational boundaries, rather than dissolving them (III). Continuous learning is central, leveraging lessons learned from adaptations made under pressure to foster resilience and ensure effective care delivery (IV). Coordinating care in organizational borderlands—the spaces where professional roles and organizational boundaries intersect—requires continuous communication, negotiation, and shared decisionmaking. Adaptability enables healthcare professionals to navigate the complexities of real-world care and bridge the gap between protocols and practice by balancing standardized procedures with context-specific, flexible decision-making. Conclusion: Well-defined boundaries, established collaboration pathways, and adaptability are necessary to overcome challenges in fragmented healthcare systems. When maintained with flexibility, boundaries facilitate coordination by defining roles and responsibilities while still allowing healthcare professionals to adapt to emerging situations. Rather than needing to be dissolved, boundaries provide a structure that reduces ambiguity and supports effective collaboration. Striking a balance between stability and adaptability is, therefore, essential for achieving seamless care for patients with complex care needs.

Introduction Making decisions about the appropriate level of care is a significant challenge for healthcare professionals, especially when older patients present with diffuse symptoms. Collaboration between ambulance services and primary care may promote a comprehensive understanding of patient needs. However, such collaboration remains limited, potentially leading to lower care quality and higher costs. There is a need to understand how collaboration can be effectively implemented. This scoping review aims to explore existing models of collaboration between ambulance services and primary care, identifying their characteristics, outcomes and current research gaps. Methods and analysis This scoping review will follow the methodological framework proposed by Arksey and O’Malley, supplemented with recommendations from the Joanna Briggs Institute Handbook for Scoping Reviews. A comprehensive literature search will be conducted in PubMed, CINAHL, Web of Science and Scopus. In addition, Google Scholar, Overton, SwePub and the Swedish national library database Libris will be searched for relevant grey literature. The review will include studies published from January 2014 to the present. Data will be analysed descriptively, with findings categorised by collaboration models and patterns identified through inductive analysis to address the research questions. The review will apply the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews to present the results. Ethics and dissemination This review is the first stage of an overarching research study to develop a model for extended collaboration between ambulance services and primary care (the ECAP project). Results will be disseminated through peer-reviewed publications, conference presentations and sharing with ambulance services and primary care stakeholders to inform practice and policy. This scoping review protocol has been registered on the Open Science Framework (https://osf.io/nrkm5/). No participants will be involved at this stage, and the selected literature is publicly available, so no ethical approval will be required for this scoping review.

Background: Although coordination of care and integrated care models aim to enhance patient satisfaction and perceived care quality, evidence regarding their practical implementation remains scarce. Understanding the nuances of collaboration across care providers to achieve effective coordination of care is imperative for seamless care integration. The aim of this study was to construct a grounded theory of how inter-organizational collaboration is performed to support coordination of care for patients with complex care needs. Methods: A qualitative design with a constructivist grounded theory approach was applied. In total, 86 participants with diverse backgrounds were recruited across multiple care settings, including hospitals, ambulance services, primary care centers, municipal home healthcare and home care services. The grounded theory was developed iteratively, based on a combination of observations and interviews, and using constant comparative analysis. Results: Coordination of care, a complex process that occurs across interconnected healthcare organizations, is manifested as “Negotiating care in organizational borderlands.” Care coordination evolves through a spectrum of inter-organizational collaboration, ranging from “Dividing care by disease-specific expertise” to “Establishing paths for collaboration” and ultimately “Co-constructing a comprehensive whole.” These categories highlight the challenges of coordinating care across both professional and organizational boundaries. In the multifaceted healthcare landscape, effective care coordination occurs when healthcare professionals actively bridge the divides, leveraging their collective expertise. Importantly, organizational boundaries may serve a purpose and should not be dissolved to facilitate effective care coordination. Conclusions: The key to effective care coordination lies in robust inter-organizational collaboration. Even when patients receive integrated care, healthcare professionals may have fragmented roles. This research emphasizes the importance of clearly defined lines of accountability, reinforcing mutual responsibility and facilitating bridging of professional and organizational boundaries. Healthcare professionals and policymakers can use these insights to effectively utilize inter-organizational collaboration in supporting care coordination for patients with complex care needs.

Aim: To explore frontline decision‐making, adaptation, and learning in ambulance care during the evolving COVID‐19 pandemic. Design: Descriptive and interpretative qualitative study. Methods: Twenty‐eight registered nurses from the Swedish ambulance services described 56 critical incidents during the COVID‐19 pandemic through free‐text questionnaires. The material was analysed using the Critical Incident Technique and Interpretive Description through the lens of potential for resilient performance. Results: The findings were synthesized into four themes: ‘Navigating uncharted waters under never‐ending pressure’, ‘Balancing on the brink of an abyss’, ‘Sacrificing the few to save the many’ and ‘Bracing for the next wave’. Frontline decision‐making during a pandemic contribute to ethical dilemmas while necessitating difficult prioritizations to adapt and respond to limited resources. Learning was manifested through effective information sharing and the identification of successful adaptations as compared to maladaptations. Conclusions: During pandemics or under other extreme conditions, decisions must be made promptly, even amidst emerging chaos, potentially necessitating the use of untested methods and ad‐hoc solutions due to initial lack of knowledge and guidelines. Within ambulance care, dynamic leadership becomes imperative, combining autonomous frontline decision‐making with support from management. Strengthening ethical competence and fostering ethical discourse may enhance confidence in decision‐making, particularly under ethically challenging circumstances. Impact: Performance under extreme conditions can elevate the risk of suboptimal decision‐making and adverse outcomes, with older adults being especially vulnerable. Thus, requiring targeted decision support and interventions. Enhancing patient safety in ambulance care during such conditions demands active participation and governance from management, along with decision support and guidelines. Vertical communication and collaboration between management and frontline professionals are essential to ensure that critical information, guidelines, and resources are effectively disseminated and implemented. Further research is needed into management and leadership in ambulance care, alongside the ethical challenges in frontline decision‐making under extreme conditions. Reporting Method: Findings are reported per consolidated criteria for reporting qualitative research (COREQ). Patient or Public Contribution: No Patient or Public Contribution.