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Holmberg, Mats, Med.Dr.ORCID iD iconorcid.org/0000-0003-1878-0992
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Hammarbäck, S., Holmberg, M., Wiklund, L. & Bremer, A. (2023). Ambulance clinicians’ responsibility when encountering patients in a suicidal process. Nursing Ethics
Öppna denna publikation i ny flik eller fönster >>Ambulance clinicians’ responsibility when encountering patients in a suicidal process
2023 (Engelska)Ingår i: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989Artikel i tidskrift (Refereegranskat) Epub ahead of print
Abstract [en]

Background: Even though the traditional focus in emergency care is on life-threatening medical crisis, ambulance clinicians frequently encounter patients with mental illness, including suicidal ideation. A suicide is preceded by a complex process where most of the suicidal ideation is invisible to others. However, as most patients seek healthcare in the year before suicide, ambulance clinicians could have an important part to play in preventing suicide, as they encounter patients in different phases of the suicidal process. Aim: The aim of this study was to describe ambulance clinicians’ conceptions of responsibility when encountering patients in a suicidal process. Research design: A qualitative inductive design using a phenomenographic approach was used. Participants and research context: Twenty-seven ambulance clinicians from two regions in southern Sweden were interviewed. Ethical considerations: The study was approved by the Swedish Ethical Review Authority. Findings: Three categories of descriptions captured a movement from responding to a biological being to responding to a social being. Conventional responsibility was perceived as a primary responsibility for emergency care. In conditional responsibility, the patient’s mental illness was given only limited importance and only if certain conditions were met. Ethical responsibility was perceived to have its primary focus on the encounter with the patient and listening to the patient’s life story. Conclusions: An ethical responsibility is favourable regarding suicide prevention in ambulance care, and competence development in mental illness and conversation skills could enable ambulance clinicians to have conversations with patients about suicidal ideation.

Ort, förlag, år, upplaga, sidor
SAGE Publications Ltd, 2023
Nyckelord
Ambulance clinicians, emergency medical services, ethical responsibility, phenomenography, suicidal ideation
Nationell ämneskategori
Hälsovetenskaper
Identifikatorer
urn:nbn:se:mdh:diva-62334 (URN)10.1177/09697330221149102 (DOI)000963458300001 ()2-s2.0-85152260693 (Scopus ID)
Tillgänglig från: 2023-04-26 Skapad: 2023-04-26 Senast uppdaterad: 2023-05-03Bibliografiskt granskad
Hjalmarsson, A., Östlund, G., Asp, M., Kerstis, B. & Holmberg, M. (2023). Balancing power: Ambulance personnel's lived experience of older persons' participation in care in the presence of municipal care personnel. Scandinavian Journal of Caring Sciences
Öppna denna publikation i ny flik eller fönster >>Balancing power: Ambulance personnel's lived experience of older persons' participation in care in the presence of municipal care personnel
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2023 (Engelska)Ingår i: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Patient participation is considered to promote well-being and is, therefore, central in care contexts. Care-dependent older persons living at home constitute a vulnerable population with increased ambulance care needs. Care transfers risk challenging participation in care, a challenge that can be accentuated in situations involving acute illness.Aim: To illuminate meanings of older persons' participation in ambulance care in the presence of municipal care personnel from the perspective of ambulance personnel.Method: A phenomenological hermeneutical method was used to analyse transcripts of narrative interviews with 11 ambulance personnel.Results: The ambulance personnel's lived experience of older persons' participation includes passive and active dimensions and involves a balancing act between an exercise of power that impedes participation and equalisation of power that empowers participation. The main theme 'Balancing dignity in relation to manipulating the body' included the themes Providing a safe haven and Complying with bodily expressions, which means shouldering responsibility for existential well-being and being guided by reactions. The main theme 'Balancing influence in relation to perceived health risks' included the themes Agreeing on a common perspective, Directing decision-making mandate, and Sharing responsibility for well-being, which means shouldering responsibility for health focusing on risks. Influence is conditional and includes performance requirements for both the older person and municipal care personnel.Conclusion: Care-dependent older persons' participation in care from the perspective of ambulance personnel means recognising passive and active dimensions involving human dignity, the ability to influence care, and optimising care efforts through collaboration. This study provides a deepened understanding of the balancing of power involved in ambulance care determining participation, where power is equalised or exercised depending on personal engagement, health risks, and available care options. The knowledge provided holds the potential to improve ambulance care to benefit older persons in critical life situations.

Nationell ämneskategori
Omvårdnad
Identifikatorer
urn:nbn:se:mdh:diva-62178 (URN)10.1111/scs.13162 (DOI)000947937400001 ()36908069 (PubMedID)2-s2.0-85150591793 (Scopus ID)
Tillgänglig från: 2023-04-05 Skapad: 2023-04-05 Senast uppdaterad: 2024-01-09Bibliografiskt granskad
Hjalmarsson, A., Östlund, G., Asp, M., Kerstis, B. & Holmberg, M. (2023). Entrusting life to professionals: A phenomenological hermeneutical study of older persons' participation in prehospital emergency care involving municipal home care and ambulance services. Scandinavian Journal of Caring Sciences
Öppna denna publikation i ny flik eller fönster >>Entrusting life to professionals: A phenomenological hermeneutical study of older persons' participation in prehospital emergency care involving municipal home care and ambulance services
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2023 (Engelska)Ingår i: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712Artikel i tidskrift (Refereegranskat) Epub ahead of print
Abstract [en]

Background: Participation in care is considered to promote safe and qualitative care. Care-dependent older persons ageing in place have increased emergency care needs, which initiate inter-organisational collaboration involving municipal home care and ambulance services. Previous research concludes that uncertainties exist regarding what participation in care means in clinical practice, which necessitates the need to illuminate the phenomenon for older persons in critical life situations.

Aim: This study aimed to illuminate meanings of participation in prehospital emergency care from the perspective of care-dependent older persons experiencing acute illness at home.

Design: This study has a qualitative design with a lifeworld approach.

Method: A phenomenological hermeneutical method was used to analyse transcribed telephone interviews with eleven care-dependent persons aged 70–93 years.

Results: Care-dependent older persons' participation in prehospital emergency care means ‘Entrusting life to professional caregivers’ when being in helpless solitude and existentially unsafe, which emphasises a deepened interpersonal dependence. Meanings of participation in care from the perspective of older persons involve Being reassured in togetherness, Being pliant in trust of emergency expertise, Being enabled through the agency of professional caregivers, and Encountering readiness in the emergency care chain.

Conclusion: Care-dependent older persons' participation in prehospital emergency care is existential and involves interpersonal dependence. Togetherness brings reassurance, safety and opportunity for emotional rest while accessing the professional caregivers' power, competence and abilities which provide opportunities for existence and movement towards well-being and continued living.

Implications for practice: Prehospital emergency care from the perspective of care-dependent older persons transcends organisational boundaries and includes the municipal mobile safety alarm service. The involved municipal and regional organisations need to provide support by implementing lifeworld-led care models and care alternatives that enable professionals to recognise the existential dimension of participation in care.

Ort, förlag, år, upplaga, sidor
John Wiley and Sons Inc, 2023
Nyckelord
ambulance services, home care services, mobile safety alarm, older persons, participation in care, phenomenological hermeneutical method, prehospital emergency care
Nationell ämneskategori
Omvårdnad
Identifikatorer
urn:nbn:se:mdh:diva-64750 (URN)10.1111/scs.13223 (DOI)001095083000001 ()2-s2.0-85175615979 (Scopus ID)
Tillgänglig från: 2023-11-15 Skapad: 2023-11-15 Senast uppdaterad: 2024-01-24Bibliografiskt granskad
Holmberg, M., Hoeck, B., Bremer, A., Kaldestad, K. & Koskinen, M. (2023). The Nordic College of Caring Science develops, supports and disseminates caring science [Letter to the editor]. Scandinavian Journal of Caring Sciences, 37(2), 313-315
Öppna denna publikation i ny flik eller fönster >>The Nordic College of Caring Science develops, supports and disseminates caring science
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2023 (Engelska)Ingår i: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 37, nr 2, s. 313-315Artikel i tidskrift, Letter (Övrigt vetenskapligt) Published
Ort, förlag, år, upplaga, sidor
WILEY, 2023
Nationell ämneskategori
Omvårdnad
Identifikatorer
urn:nbn:se:mdh:diva-62687 (URN)10.1111/scs.13179 (DOI)000989719700001 ()37195075 (PubMedID)2-s2.0-85159768575 (Scopus ID)
Tillgänglig från: 2023-05-31 Skapad: 2023-05-31 Senast uppdaterad: 2023-06-07Bibliografiskt granskad
Hjalmarsson, A., Östlund, G., Asp, M., Kerstis, B. & Holmberg, M. (2022). A matter of participation?: A critical incident study of municipal care personnel in situations involving care-dependent older persons and emergency medical services. International Journal of Qualitative Studies on Health and Well-being, 17(1), Article ID 2082062.
Öppna denna publikation i ny flik eller fönster >>A matter of participation?: A critical incident study of municipal care personnel in situations involving care-dependent older persons and emergency medical services
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2022 (Engelska)Ingår i: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 17, nr 1, artikel-id 2082062Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Purpose This study aimed at describing municipal care personnel's experiences of and actions in situations when older persons need emergency medical services (EMS) at home. Methods An inductive descriptive design adhering to critical incident technique (CIT) was used. Data were collected through interviews and free text written questionnaires, analysed in accordance with CIT procedure. Results Experiences related to the main areas of Lifesaving competence and Collaborative care. Lifesaving competence involved having sufficient knowledge to guide older persons in emergencies without organizational support. The lack of care alternatives carries dependence on inter-organizational collaboration, as well as having to accept the collaborative conditions provided by the EMS. Actions meant Adjusting to situational needs and EMS authority, which involved safeguarding the person while being directed by the EMS. Conclusions Lack of organizational support, care alternatives, and structured collaboration jeopardize care-dependent older persons' health, and ability to influence care when emergency situations occur at home. Municipal care personnel's actions as the older person's representative support human agency, allowing older persons to become active participants in care despite acute suffering. This study underlines the importance of further developing welfare policies that facilitate and regulate inter-organizational responsibilities of health and social care to favour older people.

Ort, förlag, år, upplaga, sidor
Taylor & Francis, 2022
Nyckelord
Ambulance dispatch personnel, ambulance personnel, critical incident technique, emergency medical services, emergency situations, experiences, inter-organizational collaboration, municipal care personnel, municipal home care services, older persons
Nationell ämneskategori
Omvårdnad
Identifikatorer
urn:nbn:se:mdh:diva-59402 (URN)10.1080/17482631.2022.2082062 (DOI)000811326800001 ()35703409 (PubMedID)2-s2.0-85132078328 (Scopus ID)
Tillgänglig från: 2022-06-29 Skapad: 2022-06-29 Senast uppdaterad: 2023-04-17Bibliografiskt granskad
Bratt, A. S., Johansson, M., Holmberg, M., Fagerstrom, C., Elmqvist, C., Rusner, M. & Kaldo, V. (2022). An internet-based compassion course for healthcare professionals: Rationale and protocol for a randomised controlled trial. Internet Interventions, 28
Öppna denna publikation i ny flik eller fönster >>An internet-based compassion course for healthcare professionals: Rationale and protocol for a randomised controlled trial
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2022 (Engelska)Ingår i: Internet Interventions, ISSN 2214-7829, Vol. 28Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Severe stress is one of the most common causes of sick leave in Sweden. Previous research has shown that compassion interventions for healthcare professionals can decrease work-related stress through the introduction of self-care, self-awareness, and emotion regulation abilities when experiencing difficult situations. Internet-based stress management interventions have hitherto shown promising results in reducing stress. However, further research is needed to examine the effectiveness of internet-based compassion interventions for healthcare professionals. Objective: In the present study protocol, a randomised controlled trial is described, aiming to examine the effects of an internet-based compassion course for healthcare professionals on work-related stress and stress of conscience. Method: Healthcare professionals will be offered an internet-based stress management course of five modules across a period of five weeks. The design is a randomised controlled study consisting of three groups enrolled in one of the following: a compassion course (n = 120), a cognitive behavioural stress management course (n = 120), or placed on a waitlist followed by either the compassion course or the cognitive behavioural stress management course (n = 36). We hypothesise that the internet-based compassion course would reduce the participants' stress of conscience to a greater degree compared to the other two groups. The secondary hypothesis is that the compassion course would increase the participants' professional quality of life (i.e., higher job satisfaction and lower empathy fatigue) and self-compassion. In addition, the internet-based compassion course is expected to reduce the participants' work-related stress and sick leave rates to the same degree (non-inferiority) as the cognitive behavioural stress management course and to a higher degree when compared to the waitlist condition. The primary outcome measure is the Stress of Conscience Questionnaire (SCQ) and the secondary outcome measures are the Professional Quality of Life Scale (PROQOL), the Work-related Stress Copenhagen Psychosocial Questionnaire (COPSOQ), and the Self-compassion Scale (SCS). Assessments will be performed at baseline, four weekly assessments during treatment, post-treatment (5 weeks), and follow-ups at 10 weeks, 15 weeks, and 6 months. The repeated measures data will be analysed using a generalised estimating equation for repeated measurements to examine whether changes over time differ between the groups and whether the improvements persist over time. Discussion: The clinical trial is expected to provide novel data on the effects of compassion interventions and add to the existing knowledge of internet-based interventions for stress management in healthcare professionals.

Nyckelord
Compassionate mind training course, Cognitive behavioural therapy, Healthcare professionals, Stress management course, Internet-based intervention, Stress of conscience, COGNITIVE-BEHAVIORAL THERAPY, SELF-COMPASSION, CONSCIENCE, STRESS
Nationell ämneskategori
Sociologi
Identifikatorer
urn:nbn:se:mdh:diva-58625 (URN)10.1016/j.invent.2021.100463 (DOI)000799991900003 ()2-s2.0-85116622972 (Scopus ID)
Tillgänglig från: 2022-06-08 Skapad: 2022-06-08 Senast uppdaterad: 2022-06-15Bibliografiskt granskad
Johanna, Z., Elin, V., Holmberg, M., Henrik, A. & Jonas, A. (2022). Nurses’ experiences of encountering patients with mental illness in prehospital emergency care – a qualitative interview study. BMC Nursing, 21(1), Article ID 89.
Öppna denna publikation i ny flik eller fönster >>Nurses’ experiences of encountering patients with mental illness in prehospital emergency care – a qualitative interview study
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2022 (Engelska)Ingår i: BMC Nursing, ISSN 1472-6955, E-ISSN 1472-6955, Vol. 21, nr 1, artikel-id 89Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

 Background:  Nurses working in prehospital emergency care (PEC) encounter patients with all types of health conditions. Increasingly, they are encountering patients suffering from mental illness and this trend reflects the worldwide increase in mental illness. There is very little current knowledge of encounters between nurses and patients with mental illness in 'PEC', especially from the nurses' perspectives.

 Aim:  The aim of the study is to investigate nurses' experiences of encountering patients with mental illness in 'PEC'.

 Methods:  The participants were recruited in a region in southeast Sweden (that covers approximately 5600 km2 and has 300,000 inhabitants). In total, 17 nurses consented to participate. The participants were asked to narrate their individual experience of encountering patients with mental illness. The interviews were transcribed verbatim, then analysed with qualitative content analysis.

 Results:  The result is presented in terms of three themes and eight sub-themes. The main themes are 'Lacking trust in the patient and one's own abilities', 'Being under internal and external influences' and 'Moving towards a genuine nurse-patient relationship'.

 Conclusion:  The results show that nurses strive to lay the foundation for a trusting relationship. Simultaneously nurses encountering is characterized by a mistrust and it is influenced by pre-understanding and emotions when they take care for patients. The findings could be used to develop nurses' readiness and capability to encounter patients with mental illness and to respond appropriately to the patients somatic and mental care needs.

Nationell ämneskategori
Hälsovetenskaper
Identifikatorer
urn:nbn:se:mdh:diva-58286 (URN)10.1186/s12912-022-00868-4 (DOI)000783475500001 ()2-s2.0-85128358556 (Scopus ID)
Tillgänglig från: 2022-05-24 Skapad: 2022-05-24 Senast uppdaterad: 2022-06-07Bibliografiskt granskad
Kayambankadzanja, R. K., Schell, C. O., Warnberg, M. G., Tamras, T., Mollazadegan, H., Holmberg, M., . . . Baker, T. (2022). Towards definitions of critical illness and critical care using concept analysis. BMJ Open, 12(9), Article ID e060972.
Öppna denna publikation i ny flik eller fönster >>Towards definitions of critical illness and critical care using concept analysis
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2022 (Engelska)Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 12, nr 9, artikel-id e060972Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective As 'critical illness' and 'critical care' lack consensus definitions, this study aimed to explore how the concepts' are used, describe their defining attributes, and propose potential definitions. Design and methods We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O'Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts' defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents. Results Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, 'a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility', and of critical care as, 'the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.' Conclusion The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.

Ort, förlag, år, upplaga, sidor
BMJ PUBLISHING GROUP, 2022
Nyckelord
adult intensive & critical care, accident & emergency medicine, health services administration & management
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:mdh:diva-60039 (URN)10.1136/bmjopen-2022-060972 (DOI)000852862800043 ()2-s2.0-85138991606 (Scopus ID)
Tillgänglig från: 2022-10-14 Skapad: 2022-10-14 Senast uppdaterad: 2023-08-28Bibliografiskt granskad
Carnesten, H., Asp, M. & Holmberg, M. (2021). Caring approach for patients with chest pain–Swedish registered nurses’ lived experiences in Emergency Medical Services. International Journal of Qualitative Studies on Health and Well-being, 16(1), Article ID 1901449.
Öppna denna publikation i ny flik eller fönster >>Caring approach for patients with chest pain–Swedish registered nurses’ lived experiences in Emergency Medical Services
2021 (Engelska)Ingår i: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 16, nr 1, artikel-id 1901449Artikel, forskningsöversikt (Refereegranskat) Published
Abstract [en]

Purpose: Encountering patients with chest pain iscommon for Registered Nurses (RNs) in Emergency Medical Services (EMS) who are responsible for the patient’s medical and nursing care. From a lifeworld perspective, bodily illness is related to existential suffering, requiring knowledge to asses the situation from a holistic perspective. The aim of this study is to describe the caring approach when RNs encounter patients with chest pain. Methods: A phenomenological methodology to capture RNs’ lived experiences was chosen. Seven qualitative in-depth interviews were conducted at three ambulance stations in Sweden. Results: The essence of the caring approach while encountering patients with chest pain comprises two constituents; “trust based on confidence and competence” and “the collegial striving towards the best possible care”. Trust is two-parted; trust in oneself, and striving towards gaining the patient’s trust. Competence and experience when combined, develop into confidence especially in stressful situations. The caring approach is nurtured in a well-functioning collegial team. Conclusions: This study contributes to understanding the caring approach based on the specific patient’s lifeworld in holistic EMS care. By trusting oneself, the patient, and one’s colleague, RNs in EMS shift focus from medical-orientated care to a holistic lifeworld caring approach. More research is needed on trust as a phenomenon in EMS, both from caregivers’ and patients’ perspectives. 

Ort, förlag, år, upplaga, sidor
Taylor and Francis Ltd., 2021
Nyckelord
ambulance nurse, Caring science, chest pain, collegial interaction, Emergency Medical Services, confidence, lifeworld, nursing science, phenomenology, prehospital emergency care
Nationell ämneskategori
Hälsovetenskaper
Identifikatorer
urn:nbn:se:mdh:diva-53849 (URN)10.1080/17482631.2021.1901449 (DOI)000634899200001 ()33779530 (PubMedID)2-s2.0-85103419074 (Scopus ID)
Tillgänglig från: 2021-04-08 Skapad: 2021-04-08 Senast uppdaterad: 2021-04-22Bibliografiskt granskad
Hjalmarsson, A., Asp, M., Östlund, G. & Holmberg, M. (2021). When older persons need Emergency Medical Services at home: a critical incident study on Swedish municipal care personnel. In: : . Paper presented at Thinking qualitatively Virtual Conference, Online, 5-9 July 2021 (pp. 92-93). , 20
Öppna denna publikation i ny flik eller fönster >>When older persons need Emergency Medical Services at home: a critical incident study on Swedish municipal care personnel
2021 (Engelska)Konferensbidrag, Poster (med eller utan abstract) (Övrigt vetenskapligt)
Abstract [en]

Older persons in Sweden can continue to live at home, assisted by the municipal home care services. Older age raises the risk of emergency situations that require involvement of the emergency medical services (EMS). Such situations intersect two different organizations, the municipal social care services and the regional EMS. The transfer of care between the organizations might impact the older persons´ health, and quality of life or death. Research question: How do municipal care personnel describe their experiences of and actions in situations when older persons are in need of EMS? Design: The study has a qualitative inductive design. Sample: Municipal care personnel (n=19) consisting of home care personnel and security alarm responders. Data collection and analysis: Data was collected through group interviews and free text written critical incidents analyzed according to critical incident technique. Results: Experiences related to the two main areas Lifesaving competence, and Collaborative care, which encompass the four categories Emergency knowledge, Companionship in a vulnerability, Limited caring options and Conditions for EMS collaboration. Actions related to the one main area Adjusting actions to actual conditions, which encompasses the three categories Adapting care to emergency needs, Safeguarding the person, and Adapting actions to EMS leadership.

Nyckelord
care personnel, EMS, municipal home care, older persons
Nationell ämneskategori
Omvårdnad
Forskningsämne
vårdvetenskap
Identifikatorer
urn:nbn:se:mdh:diva-56143 (URN)000726772800252 ()
Konferens
Thinking qualitatively Virtual Conference, Online, 5-9 July 2021
Tillgänglig från: 2021-10-12 Skapad: 2021-10-12 Senast uppdaterad: 2023-02-23Bibliografiskt granskad
Organisationer
Identifikatorer
ORCID-id: ORCID iD iconorcid.org/0000-0003-1878-0992

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