Högskolan i Skövde

Background: Adolescents who experience gender dysphoria are exposed to harassment, discrimination, and violence in the school environment to a greater extent than other students. The school nurses play a key professional role in supporting the health of these vulnerable students.

Methods: A qualitative descriptive design. Semi-structured interviews were conducted with eight school nurses in Sweden and analysed via qualitative content analysis.

Results: School nurses perceived students with gender dysphoria to struggle with anxiety, depression, and self-harm. Some school nurses reported an open school climate, while others expressed the opposite. School nurses express it as vital to establish a relationship to instil courage, strengthen and provide support. They strive to be accessible, signal openness, show understanding, and listen. School nurses call for a collective effort from school staff to elevate competence. They believe that there is a lack of education and directives from management on how school staff should work with students with gender dysphoria.

Conclusions: The school nurses highlight a connection between gender dysphoria and ill health among students, which school nurses should be aware of to better identify these vulnerable students’ needs through the professional role of the school nurse. The health dialogue and the health forms are a key tool for initiating conversations and providing support. The school nurse plays a role in creating inclusion, such as adapting the school environment. The lack of self-reported competence described by school nurses, can be overcome by openness regarding the topic.

Clinical trial number: Not applicable.

SYFTE Att beskriva skolsköterskors erfarenheter av interaktion med elever med könsdysfori.

BAKGRUND Förekomsten av könsdysfori har ökat bland ungdomar. Ungdomar som upplever könsdysfori är mer utsatta för trakasserier, diskriminering och våld än sina jämnåriga. Skolsköterskan spelar en central roll i att stödja elevers fysiska och psykiska hälsa.

METOD Semistrukturerade intervjuer genomfördes med åtta skolsköterskor, med erfarenhet av att möta elever med könsdysfori. Data analyserades enligt kvalitativ innehållsanalys. 

RESULTAT Skolsköterskorna beskriver att elever med könsdysfori ofta brottas med ångest, depression och självskadebeteende. Vissa beskriver ett öppet och accepterande skolklimat, medan andra upplever en mer negativ skolmiljö. Skolsköterskorna betonar vikten av att etablera en god relation, vara lyhörda, inge mod, vara tillgänglig och ge stöd till eleven. Resultatet visar på behovet av en ökad kompetens hos skolpersonal för att skapa en främjande skolmiljö och förståelse för elever med könsdysfori. Skolsköterskorna beskriver behovet av samordnade insatser inom och utanför skolan för att främja elevens psykisk hälsa. 

SLUTSATS Sambandet mellan könsdysfori och ohälsa behöver synliggöras och diskuteras inom skolan. Hälsosamtalet är ett verktyg för skolsköterskan att initiera samtal om könsidentitet och ge stöd. Inkludering kräver både kompetens och ett respektfullt bemötande. Bristande kompetens kan  övervinnas genom att visa nyfikenhet, öppenhet och acceptans gentemot elever med könsdysfori.

Background: Young transgender persons who attend school are especially exposed to harassment, bullying, discrimination and violence in the school environment, experiencing an increased sense of mental and physical ill-health. School nurses work health promoting in schools and therefore have a unique opportunity to promote health among transgender students. There is however limited research on school nurses’ experiences of working with transgender students.

Aim: To illuminate school nurses’ experiences of interacting with and supporting students with transgender experiences.

Method: An inductive qualitative study with data collected through eight semi-structured interviews, analyzed through an inductive qualitative content analysis according to Graneheim and Lundman. The analysis was on the manifest level, where the steps were conducted in discussion within the research group to reach consensus through each step to ensure their connection to the aim. The analysis resulted in the findings, which is presented in two main categories with three sub-categories each.

Findings: The school nurses supported the students with trans experiences through conversations during the health dialogues, building a trusting relationship with the students, and by being a spokesperson and for the students, with other students, teachers and parents. The school nurses also experienced uncertainty in which was the proper actions to support the students with transgender experiences and feared acting wrongly and therefore not supporting the students adequately or even harming students.

Conclusions: The school nurses’ role in meeting these students is complex, where the school nurse work to build relationships with the students, but lack knowledge and tools. The lack of support and knowledge creates an ambivalence in how to best support these students, placing the school nurse before ethical dilemmas. The school nurses found support in the collaboration with the school counselor, as were the youth health clinics. School nurses should therefore, besides added education, be provided with arenas to discuss ethical dilemmas surrounding gender identity with other professionals who work in the school environment, or with adolescents.

SYFTE Att beskriva skolsköterskors erfarenhet av att möta elever med transerfarenhet.

BAKGRUND Allt fler barn och ungdomar upplever könsdysfori och osäkerhet över sin könsidentitet. Skolan är en betydelsefull arena där barn och unga spenderar stor del av sin vardag. Elever med transerfarenhet är i högre grad utsatta för mobbing och har högre risk för psykisk och fysisk ohälsa. Skolsköterskor har en central roll i att stödja elever med transerfarenhet.  

METOD Semistrukturerade intervjuer genomfördes med åtta skolsköterskor på högstadium och gymnasium. Intervjuerna analyserades enligt kvalitativ innehållsanalys.

RESULTAT Skolsköterskorna betonade betydelsen av tillit i mötet mellan elev och skolsköterska, för att skapa en trygg dialog kring trans- och könsidentitet. Det finns en stark vilja stödja elever med transerfarenhet samtidigt som utmaningar som bristande kunskap och ambivalens kring det stöd och vård som erbjuds till barn och unga. Skolsköterskorna uttryckte en oro över att eleven i framtiden skulle ångra sina beslut. En genomgående känsla av osäkerhet och rädsla för att göra fel beskrevs av skolsköterskorna, vilket kunde leda till att elever med transerfarenhet inte alltid fick stöd. 

SLUTSATS Det förekommer en brist på både kunskap och stödjande verktyg samt riktlinjer för skolsköterskor. Vilket medför att skolsköterskor känner osäkerhet i mötet och i att stödja elever med transerfarenhet. Trots detta framhålls det som avgörande att erbjuda ett respektfullt och bekräftande bemötande för att skapa en trygg miljö för dessa elever.

Background: Nursing education entails extensive training across varying settings where nursing students can practice their theoretical knowledge and practical skills for their future profession. Skills in evidence-based practice are pivotal competences for nurses and need to evolve from novice to expert skills. During the COVID-19 pandemic, Sweden had a unique approach to restrictions. The conditions for nursing students to apply their practical skills changed, as the COVID-19 pandemic influenced nursing education. Previous studies lacked focus on the clinical and practical aspects of the nursing education during the COVID-19 pandemic. Such experiences can provide valuable knowledge for nursing education, especially in preparing for future crises as well as understanding the needs of the nurses who were educated during the pandemic. The aim of this study is therefore to highlight the essence and understanding of the experiences of nursing students undertaking nursing education in Sweden during the COVID-19 pandemic.

Methods: A qualitative interview study of nine nursing students recruited through a convenience sample. The data was analyzed through a phenomenological hermeneutic approach, chosen for two of the opportunity to use the researcher’s preunderstanding. The result is presented in three main themes; Being disappointed yet accepting the situation, Feelings of uncertainty and the covid-19 pandemic provided new insights, the two latter are further divided into a total of eight subthemes.

Results: The COVID-19 pandemic affected nursing students’ experience with clinical learning and contributed to their unique experiences. Compared to students who began their nursing education during the COVID-19 pandemic, those who started before the outbreak faced more significant adjustments in their learning. It was seen as positive for the student’s future profession that a great focus was placed on how to prevent the spread of infection. The students experienced loneliness in the lack of support from other students, and fear of infecting or being infected. Furthermore, there was a lack of clinical placement and training hours, leading to worries of not being prepared. Opinions differed between the students on whether the clinical knowledge they acquired during the training was sufficient. Whilst the vast majority wanted more time for practical elements and training, they emphasized that this was not solely caused by the impact of the COVID-19 pandemic but an effect of the design of the education.

Conclusions: The study showed that, through the shared experiences of nursing students who studied during the COVID-19 pandemic, education and the acquisition of clinical skills were affected. The students experienced feelings of loneliness in their isolation and fear of infecting or being infected throughout their education. However, the majority found themselves with a sense of acceptance of the situation, while there were also experiences of pausing the education because of the pandemic. Being a part of the group of nursing students participating in education during the COVID-19 pandemic gave new insights into the nursing profession regarding hygiene routine and hindering factors in communication with patients. Nursing students who have gone through their education during the COVID-19 pandemic have unique experiences such as preparedness of coming pandemics and the importance of reflection surrounding clinical education that are worthy of sharing. These experiences could be helpful when developing nursing education in the future and preparing for possible future crisis situations.

Background: Older persons’ use of digital technology is becoming more prominent due to society’s heavy reliance on mobile and web applications. A positive attitude has been detected among older persons regarding the use of mobile solutions. Digital technology is increasingly used in the provision of health and social care, which can help older persons continue to be independent, and in turn can contribute to older persons’ overall well-being and sense of safety. However, current digital technology has been found to be difficult for older persons. Additional explorations into older persons’ experiences using digital technology are therefore relevant.

Method: A qualitative design was used with data collected using semi-structured interviews with 17 older persons in the age span 72–101, living in 12 diferent municipalities. The older persons were admitted to municipality health care. Interviews were conducted in the older persons home, and were audio recorded. The recordings were transcribed and analyzed through a qualitative conventional content analysis. The study method was compliant with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results: The analysis resulted in two main categories; Enrichment, dependance and mixed feelings of using digital technology in daily life and Divided preferences and use of digital technology in contact with health and social care. The first is divided into three sub-categories; divided usage and feelings about digital technology, enriching daily life with digital technology, and need for support when using digital technology. The second is divided into two; divided experiences regarding digital communication with health and social care and a longing for information about healthcare through digital technology.

Conclusion: The diversity showed how older persons cannot be seen as a homogeneous group regarding the use of digital technology. Individual preferences of older persons should be acknowledged by health care professionals and policy makers prior to deciding whether the use of digital technology is preferable, and in which situations. Support and education for older person in using digital technology is essential, as is involving older persons in designing the digital technology that is developed for them to use. Otherwise, older persons may become more dependent on others to manage their everyday life.

The meal environment is the first impression of a meal, and, if it is not appealing, it lowers the willingness to eat. Malnutrition is the registered nurses’ (RN) responsibility in the municipality. However, the responsibility of the meal environment is unclear. Therefore, semi-structured interviews with 10 nurses were held, aiming to explore RNs’ experiences of meal environment within long-term care facilities for older persons, analyzed through qualitative content analysis. The study method was compliant with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. The meal environment became a grey area of responsibility, overshadowed by focus on nutrition for the RN. The RN expressed how they did not consider it part of their role to create a positive mealtime environment, avoiding the meal environment at mealtimes. However, they experienced an obstacle of raising these needs were lack of time and a stagnant view of the division of labor between the RN and assistant nurse, leading to the meal environment becoming no one’s responsibility. 

Many older patients receive health care from several different healthcare organizations, which may lead uncertainty about the responsibility for their healthcare needs. Integrated care has been argued to aid the healthcare system by addressing the challenge of the complex care needs of older patients with multiple health problems. Previous research has stated that integrated care models often have been developed with a focus on a single diagnosis, which risks overlooking the extensive and complex care needs of older patients. Prior research has also expressed the need to deepen knowledge about how integrated care models influence health care professionals, patients and their next of kin. Moreover, it is important to understand how the COVID-19 pandemic affected integrated care models which may expand knowledge about integrated home health care in crisis situations.

The overall aim is to study expectations, perceptions and experiences of integrated home health care through the perspective of registered nurses, physicians, patients and their next of kin.

Inductive qualitative designs where data was collected through interviews and field notes in the setting of the mobile integrated care model with a home health care physician (MICM) with registered nurses, physicians and patients and next of kin. Analysis was conducted using qualitative content analysis, phenomenography, and thematic analysis.

The emphasis on person-centered care in the MICM was evident in the perceptions of the healthcare professionals about the patients and their next of kin, whom they viewed as persons, not simply recipients of health care. Differences were found in the health care provided in the MICM and in comparison, to other healthcare organizations which did not align with the person-centered care ethics. However, providing health care to patients in their own home benefited the provision of person-centered care – the value base of the MICM. The MICM was created with the goal of implementing individually tailored and coherent health care with increased continuity. The healthcare professionals viewed individual medical healthcare plans as co-created with each patient, and yet no patient could recall participating in this co-creation. The coherency of the MICM was regarded as having been improved by teamwork between the registered nurse and the home healthcare physician. Collaborations with other healthcare professionals rarely occurred and should be improved in the future. Participants reported varying experiences of continuity in the MICM, which influenced the possibility of building relationships. Providing continuity with a home healthcare physician for patients is therefore preferable. The work described in this thesis was conducted during the COVID-19 pandemic. The thesis provides unique insights into an integrated care model during a crisis situation, which the healthcare system may face in similar or different ways in the future. The MICM was upheld as the best way to work in home health care, especially as patients and their next of kin regarded the model as making their daily lives easier.

An increasing number of older persons have complex health care needs. This, along with the organizational principle of remaining at home, emphasizes the need to develop collaborations among organizations caring for older persons. A health care model developed in Sweden, the Mobile Integrated Care Model aims to promote work in teams across organizations. The aim of the study was to describe nurses’ experiences in working and providing health care in the Mobile Integrated Care Model in the home with home health care physicians. Semi-structured interviews were conducted with 18 nurses and analyzed through qualitative content analysis. The method was compliant with the COREQ checklist. A mutually trusting collaboration with physicians, which formed person-centered care, created work satisfaction for the nurses. Working within the Mobile Integrated Care Model was negatively impacted by being employed by different organizations, lack of time to provide health care, and physicians’ person-centered work abilities.

Background

The organizational principle of remaining at home has offset care from the hospital to the home of the older person where care from formal and informal caregivers is needed. Globally, formal care is often organized to handle singular and sporadic health problems, leading to the need for several health care providers. The need for an integrated care model was therefore recognized by health care authorities in one county in Sweden, who created a cross-organisational integrated care model to meet these challenges. The Mobile integrated care model with a home health care physician (MICM) is a collaboration between regional and municipal health care. Descriptions of patients’ and next of kin’s experiences of integrated care is however lacking, motivating exploration.

Method

A qualitative thematic study. Data collection was done before the patients met the MICM physician, and again six months later.

Results

The participants expected a sense of relief when admitted to MICM, and hoped for shared responsibility, building a personal contact and continuity but experienced lack of information about what MICM was. At the follow-up interview, participants described having an easier daily life. The increased access to the health care personnel (HCP) allowed participants to let go of responsibility, and created a sense of safety through the personalised contact and continuity. However, some felt ignored and that the personnel teamed up against the patient. The MICM structure was experienced as hierarchical, which influenced the possibility to participate. However, the home visits opened up the possibility for shared decision making.

Conclusion

Participants had an expectation of receiving safe and coherent health care, to share responsibility, personal contact and continuity. After six months, the participants expressed that MICM had provided an easier daily life. The direct access to HCP reduced their responsibility and they had created a personalised contact with the HCP and that the individual HCP mattered to them, which could be perceived as in line with the goals in the shift to local health care. The MICM was experienced as a hierarchic structure with impact on participation, indicating that all dimensions of person-centred care were not fulfilled.