Introduction

Clinical reasoning (CR) among healthcare professionals working in emergency medical services (EMS) who focus on ambulance care is a vital part of ensuring timely and safe patient care. The EMS environment continually fluctuates, so clinicians constantly need to adapt to new situations. Organizational support is described as important for CR, but overall, research on organizational influences for CR in an EMS context is lacking. An increased understanding of these influencing factors can assist in the development of EMS by strengthening CR among clinicians. Therefore, the purpose of this study was to investigate the organizational factors influencing EMS clinicians’ CR.

Methods

Using a qualitative single case study design, an EMS organization in southwestern Sweden was explored. Data were collected from participant observations of patient encounters, individual and group interviews with clinicians and organizational representatives, and organizational document audits. Data were analyzed using qualitative content analysis and triangulation of data sources.

Results

The results revealed several organizational influencing factors. Collaboration and information sharing internally and externally were emphasized as essential components influencing CR. Additionally, the structure for the clinicians’ ‘room for action’ appeared confused and created uncertainties for CR related to decision mandates.

Conclusion

The conclusion is that organizational factors do play an important role in clinicians’ CR. Moreover, the EMS community needs to develop suitable forums for discussing and developing these influencing factors across organizational hierarchies. Finally, clarification is needed on clinicians’ ‘room for action’ within their own organization but also with possible collaborators.

HUVUDBUDSKAP

• Över 100 avhandlingar har i dagsläget skrivits om den prehospitala akutsjukvården i Sverige.
• Dessa täcker ett omfattande kunskapsfält, allt ifrån prognostiska faktorer vid akut sjukdom till ambulans personalens psykiska och fysiska hälsa.
• Endast ett kunskapsområde har belysts mera om fattande, och det är hjärt–lungräddning vid plötsligt hjärtstopp.
• Vården av patienter med psykisk ohälsa har inte belysts i någon avhandling.
• Det finns stora kunskapsluckor, och vidare forskning inom området behövs.

This article examines and exemplifies how existential philosophy can provide a deeper understanding of existential issues in a caring context. Existential philosophy, including lifeworld theory, is treated both as an epistemology for the development of research methods and inspiration for analysis and discussions in caring science research. The significance of the lifeworld is also highlighted as a guide to perform and enable caring and caring didactics, along with short descriptions where existential philosophy has previously influenced the development of caring science. The concept of existential caring science is suggested as a research area for research on existential and meaning-oriented phenomena.

In emergency medical services (EMS), the clinical reasoning (CR) of registered nurses (RNs) working in ambulance care plays an important role in providing care and treatment that is timely, accurate, appropriate and safe. However, limited existing knowledge about how CR is formed and influenced by the EMS mission hinders the development of service provision and decision support tools for RNs that would further enhance patient safety. To explore the nature of CR and influencing factors in this context, an inductive case study examined 34 observed patient–RN encounters in an EMS setting focusing on ambulance care. The results reveal a fragmented CR approach involving several parallel decision-making processes grounded in and led by patients’ narratives. The findings indicate that RNs are not always aware of their own CR and associated influences until they actively reflect on the process, and additional research is needed to clarify this complex phenomenon.

Syfte: Att beskriva prehospital akutsjukvård som ett potentiellt forskarutbildningsämne utifrån avhandlingar som skrivits och försvarats i Sverige inom detta kunskapsområde.

Metod: Systematisk och manuell sökning har gjorts via MEDLINE (PubMed) och kontakt med lärosäten.

Resultat: Totalt har 80 doktorsavhandlingar och två licentiatavhandlingar identifierats inom kunskapsområdet prehospital akutsjukvård. Avhandlingarna har försvarats under tidsperioden 1982–2021. Produktiviteten har succesivt ökat med 31 avhandlingar som försvarats under den senaste femårsperioden. Flest avhandlingar har skrivits vid Göteborgs Universitet (n=27) Karolinska Institutet (n=22) och Umeå Universitet (n=9). Avhandlingarna har skrivits av 51 sjuksköterskor, 28 läkare, en statistiker, en socionom, en präst och en folkhälsovetare (en avhandling redovisade två professioner; sjuksköterska och läkare). Kvinnor har varit författare i 48%. Avhandlingarna har delats in i följande övergripande kunskapsområden med i några fall även tillhörande undergrupper: A. Akut sjukdom, A1) Prognostiska faktorer (n=25) samt A2) Patient och anhörigperspektiv (n=8); B. Katastrof (n=6); C. Etik och värderingar (n=3); D. Vård- och arbetsmiljö (n=2); E. Kompetens, lärande och utbildning, E1) Ambulanssjuksköterska (n=5) samt E2) Hjärt-lungräddning (n=2 ); F. Trauma och smärta, F1) Skador och räddning (n=4 ), F2) Smärta (n=1) samt F3) Hypotermi (n=4); G. Akuta vårdprocesser och prioritering, G1) Resursutnyttjande (n=1) samt G2) Larmcentral och samverkan (n=8); H. Vårdande bedömning och beslut, H1) Vårdande förhållningssätt (n=3), H2) Diagnostisk bedömning och beslutsstöd (n=6) samt H3) Identifikation av sjukdom och vårdnivå (n=4).

Konklusion: Antalet doktorsavhandlingar inom prehospital akutsjukvård är i ökande. Majoriteten av författarna är sjuksköterskor. Avhandlingarna täcker ett brett spektrum av kunskapsområden, men prognostiska faktorer vid Akut sjukdom är dominerande. Könsfördelningen är acceptabel. Patient- och anhörigperspektivet är sparsamt belyst liksom vissa patientgrupper, t.ex. infektioner och trauma. Forskningen inom kunskapsområdet inleddes med fokus på överlevnad vid hjärtstopp utanför sjukhus. Under åren har forskningsområdet vidgats till allt bredare problemområden; vård på rätt vårdnivå är ett sådant exempel.  

Aim: To describe prehospital emergency care as a potential doctoral research education subject based on doctoral theses that have been written and defended in Sweden. 

Method: Systematic and manual searches have been done via MEDLINE (PubMed) and contact with higher education institutions in Sweden. 

Results: In total, 80 doctoral theses and two licentiate theses were identified within the prehospital emergency care area of expertise. They were defended during 1982-2021. Productivity has successively increased with 31 theses being defended during the last five years (2017-2021). The highest number of theses were written and defended at the University of Gothenburg (n=27), the Karolinska Institute (n=22), and the University of Umeå (n=9). These theses have been written by 51 nurses, 28 physicians, one statistician, one socio economist, and one public health specialist (one thesis was written by a person who had both a nurse and physician education). Women were the authors of 48% of the theses. The theses have been divided into the following areas of expertise and in some cases associated subgroups: A. Acute disease, A1) Prognostic factors (n=255) and A2) Patient and next of kin perspective (n=8); B. Disaster (n=6); C. Ethics and values (n=3); D. Workers’ health and environment (n=2); E. Competence, learning and education, E1) Ambulance nurse (n=5) and E2) Cardiopulmonary education (n=2); F. Trauma and pain, F1) Injury and saving (n=4), F2) Pain (n=1) and F3) Hypothermia (n=4); G. Emergency care processes and priority, G1) Resource utilization (n=1) and G2) Dispatch center and cooperation (n= 8); H. Caring assessments and decisions, H1) Caring approach (n=3), H2) Diagnostic assessments and decisions (n=6) and H3) Identification of disease and level of care (n=4).

Conclusion: The number of doctoral theses in prehospital emergency care is increasing. Nurses are the majority of the authors. Theses cover a broad spectrum of areas of expertise but prognostic factors in acute disease dominate. The distribution of sex among the authors is acceptable. The patient and next of kin perspective is sparsely illuminated as well as some large patient groups, such as those with trauma and infection. Research in prehospital emergency care started with a focus on survival after out-of-hospital cardiac arrest. But over the years, the area of expertise has broadened to include broader problem areas; optimal level of care is one such example.

Emergency care nurses (ECNs) face several challenges when they assess patients with different symptoms, signs, and conditions to determine patients’ care needs. Patients’ care needs do not always originate from physical or biomedical dysfunctions. To provide effective patient-centred care, ECNs must be sensitive to patients’ unique medical, physical, psychological, social, and existential needs. Clinical practice guidelines (CPGs) provide guidance for ECNs in such assessments. The aim of this study was to evaluate the quality of CPGs for comprehensive patient assessments in emergency care. A quality evaluation study was conducted in Sweden in 2017. Managers from 97 organizations (25 emergency medical services and 72 emergency departments) were contacted, covering all 20 Swedish county councils. Fifteen guidelines were appraised using the validated Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool. The results revealed that various CPGs are used in emergency care, but none of the CPGs support ECNs in performing a comprehensive patient assessment; rather, the CPGs address parts of the assessment primarily related to biomedical needs. The results also demonstrate that the foundation for evidence-based CPGs is weak and cannot confirm that an ECN has the prerequisites to assess patients and refer them to treatment, such as home-based self-care. This may indicate that Swedish emergency care services utilize non-evidence-based guidelines. This implies that ECN managers and educators should actively seek more effective ways of highlighting and safeguarding patients’ various care needs using more comprehensive guidelines.

Abstract: Clinical reasoning is the process of gathering and understanding information conducted by clinicians in the emergency medical services (EMS) so as to make informed decisions. Research on clinical reasoning spans several disciplines, but a comprehensive view of the process is lacking. To our knowledge, no review of clinical reasoning in the EMS has been conducted.

Aim: The aim was to investigate the nature, deployment, and factors influencing EMS clinicians’ clinical reasoning by means of a review.

Method: Data was collected through searches in electronic databases, networking among research teams ,colleagues and friends, “grey literature,” and through ancestry searches. A total of 38 articles were deemed eligible for inclusion and were analyzed using descriptive thematic analysis. The analysis resulted in an overarching finding -namely, the importance for EMS clinicians to adjust for perceived control in unpredictable situations. Within this finding, 3 themes emerged in terms of EMS clinicians’ clinical reasoning: (1) maintaining a holistic view of the patient; (2) keeping an open mind; and (3) improving through criticism. Seven subthemes subsequently emerged from these three themes.

Results: This review showed that EMS clinicians’ clinical reasoning begins with the information that they are given about a patient. Based on this information, clinicians calculate the best route to the patient and which equipment to use, and they also assess potential risks. They need to be constantly aware of what is happening on the scene and with the patient and strive to control the situation. This striving also enables EMS clinicians to work safely and effectively in relation to the patient, their relatives, other clinicians, associated organizations, and the wider community. A lack of contextually appropriate guidelines results in the need for creativity and forces EMS clinicians to use “workarounds” to solve issues beyond the scope of the guidelines available. In addition, they often lack organizational support and fear repercussions such as litigation, unemployment, or blame by their EMS or healthcare organization or by patients and relatives.

Conclusion: Clinical reasoning is influenced by several factors. Further research is needed to determine which influencing factors can be addressed through interventions to minimize their impact on patient outcomes.

BACKGROUND: Patients who call for an ambulance but only have primary care needs do not always get appropriate care. The starting point in this study is that such patients should be assigned to as basic of care as possible, while maintaining high levels of patient trust and patient safety.

AIM: To evaluate patient trust and patient safety among low-priority ambulance patients referred to care at either the Community Health Centre (CHC) or the Emergency Department (ED).

METHODS: This randomized controlled trial pilot study compared the level of patient trust and patient safety among low-priority ambulance patients who were randomized into two groups: CHC (n = 105) or ED (n = 83).

RESULTS: There was a high level of trust in the care received, regardless of whether the patient received care at CHC or ED. Overall 31% fulfilled one or more of the given criteria for potentially jeopardizing patient safety.

CONCLUSION: Patient selection for the trial indicated a potential limit in patient safety. There was a high level of trust in the care received regardless of whether the patient received care. The accuracy of patient selection for the new care model needs to be further improved with the intention to enhance patient safety even further.

BACKGROUND: Symptoms related to stroke diverge and may mimic many other conditions.

AIMS: To evaluate clinical findings among patients with a clinical suspicion of stroke in a prehospital setting and find independent predictors of a final diagnosis of stroke or transient ischemic attack (TIA) METHODS: An observational multi-centre study including nine emergency hospitals in western Sweden. All patients transported to hospital by ambulance and in whom a suspicion of stroke was raised by the EMS clinician before hospital admission during a four-month period were included.

RESULTS: Of 1,081 patients, a diagnosis of stroke was confirmed at hospital in 680 patients (63%), while 69 (6%) were diagnosed as TIA and 332 patients (31%) received other final diagnoses. In a multiple logistic regression analysis, factors independently associated with a final diagnosis of stroke or TIA were increasing age, odds ratio (OR) per year: 1.02, p=0.007, a history of myocardial infarction (OR: 1.77, p= 0.01), facial droop (OR: 2.81, p<0.0001), arm weakness (OR: 2.61, p<0.0001), speech disturbance (OR: 1.92, p<0.0001) and high systolic blood pressure (OR: 1.50, p=0.02), while low oxygen saturation was significantly associated with other diagnoses (OR: 0.41, p=0.007). More than half of all patients among patients with both stroke/TIA and other final diagnoses died during the five-year follow-up.

CONCLUSIONS: Seven factors including the three symptoms included in the Face Arm Speech Test (FAST) were significantly associated with a final diagnosis of stroke or TIA in a prehospital assessment of patients with a suspected stroke. This article is protected by copyright. All rights reserved.

Increased knowledge is needed about what self-care means from the patients’ perspective, especially since the patient population with type 2 diabetes has been rising. The aim was to describe self-care, as experienced by patients with newly diagnosed type 2 diabetes. This study adopted a phenomenological approach. Eight patients were interviewed. A combination of photos and interviews were used. The essential meaning of self-care was found to be an existential struggle that evokes feelings of being in-between one’s old unhealthy life and a new healthier one. In this in-between condition, tension exits between contradictorily emotions of anxiety, hopelessness and hope. This struggle also means questioning one’s identity. It is important that diabetes nurses create an opening for reflection and dare to challenge their patients to reflect on this existential struggle.