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Brus, O., Cao, Y., Carlborg, A., Engström, I., von Knorring, L. & Nordenskjöld, A. (2024). Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial. Journal of ECT
Open this publication in new window or tab >>Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial
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2024 (English)In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVES: This study aimed to compare the long-term effects of maintenance electroconvulsive therapy (M-ECT) with medication and medication only in patients with depression.

METHODS: A randomized controlled trial of 1 year of M-ECT with medication or medication only investigated relapse/recurrence among 56 patients in remission after electroconvulsive therapy (ECT) for depression was conducted. The results of the first year are published already and showed a significant advantage of M-ECT with medication.The current study was a long-term follow-up. When the randomized treatment allocation ended, medication was continued in both groups but M-ECT was terminated. Patients were followed for up to 10 years via Swedish national registers until the study endpoint of a new psychiatric diagnosis as an inpatient, suicide, suspected suicide, or death of another cause. Time to relapse was compared between the M-ECT with medication group and the medication-only group using Kaplan-Meier estimates.

RESULTS: The median follow-up time was 6.5 years for the M-ECT and medication group and 3.1 years for the medication-only group. One year after randomization 22 patients remained in the M-ECT and medication group, and 14 patients remained in the medication-only group. Relapse patterns between the treatment groups after the completion of M-ECT seemed to be similar according to visual inspection.

CONCLUSIONS: This long-term follow-up study suggests that most of the benefit achieved during the treatment period with M-ECT is maintained over several years, but the small sample size, with accompanying large statistical imprecision, makes the results uncertain. More long-term studies of M-ECT are required.Trial registration: ClinicalTrials.gov identifier: NCT00627887.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2024
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-111028 (URN)10.1097/YCT.0000000000000983 (DOI)38232249 (PubMedID)
Funder
Region Örebro County
Note

Uppsala-Örebro Regional Research Council and Research Committee of Örebro County Council, Örebro, Sweden, supported the research

Available from: 2024-01-30 Created: 2024-01-30 Last updated: 2024-01-30Bibliographically approved
Engström, I., Hansson, L., Ali, L., Berg, J., Ekstedt, M., Engström, S., . . . Lytsy, P. (2023). Relational continuity may give better clinical outcomes in patients with serious mental illness: a systematic review. BMC Psychiatry, 23(1), Article ID 952.
Open this publication in new window or tab >>Relational continuity may give better clinical outcomes in patients with serious mental illness: a systematic review
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2023 (English)In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 23, no 1, article id 952Article, review/survey (Refereed) Published
Abstract [en]

BACKGROUND: Continuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.

METHODS: Eleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.

RESULTS: We identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.

CONCLUSIONS: The results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023
Keywords
Continuity of care, Health care utilization, Mortality, Relational continuity, Serious mental Illness
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-110459 (URN)10.1186/s12888-023-05440-1 (DOI)001127438000001 ()38110889 (PubMedID)2-s2.0-85180205377 (Scopus ID)
Funder
Örebro University
Available from: 2023-12-21 Created: 2023-12-21 Last updated: 2024-01-22Bibliographically approved
Lynøe, N., Lindblad, A., Engström, I., Sandlund, M. & Juth, N. (2023). Values at stake at the end of life: Analyses of personal preferences among Swedish physicians. Clinical Ethics, 18(2), 239-244
Open this publication in new window or tab >>Values at stake at the end of life: Analyses of personal preferences among Swedish physicians
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2023 (English)In: Clinical Ethics, ISSN 1477-7509, E-ISSN 1758-101X, Vol. 18, no 2, p. 239-244Article in journal (Refereed) Published
Abstract [en]

Background: Physician-assisted suicide is a controversial issue and has sometimes raised emotion-laden reactions. Against this backdrop, we have analyzed how Swedish physicians are reasoning about physician-assisted suicide if it were to be legalized.

Methods and participants: We conducted a cross-sectional study and analyzed 819 randomly selected physicians’ responses from general practitioners, geriatricians, internists, oncologists, psychiatrists, surgeons, and all palliativists. Apart from the main questions about their attitude toward physician-assisted suicide, we also asked what would happen with the respondents’ own trust in healthcare if physician-assisted suicide were legalized. Response options were that trust would decrease, not be influenced, or would increase.

Results: We identified a strong statistical association between on the one hand those whose own trust would increase and who were pro physician-assisted suicide, and on the other hand those who were against physician-assisted suicide and whose own trust would decrease [relative risk: 16.7 (95% confidence interval: 10.2–27.2)]. Among those whose own trust would not be influenced (n = 456), 60% were pro pysician-assisted suicide, 16% were against, and 24% were undecided. Of those whose trust would increase or not be influenced, a large majority supported autonomy-based arguments, whereas those whose trust would decrease supported non-maleficence-based arguments.

Conclusion: Analyzing the answers after having divided respondents into those whose own trust in healthcare would decrease or increase and not be influenced brings about interesting results such as how the three groups prioritize arguments for and against physician-assisted suicide. This way of analyzing the data seems to be a promising strategy when identifying value-impregnated factual claims.

Place, publisher, year, edition, pages
Sage Publications, 2023
Keywords
Personal values, physician-assisted suicide, trust in healthcare, value-impregnated factual claims
National Category
Nursing
Identifiers
urn:nbn:se:oru:diva-110205 (URN)10.1177/14777509221077387 (DOI)2-s2.0-85124878054 (Scopus ID)
Available from: 2023-12-13 Created: 2023-12-13 Last updated: 2023-12-13Bibliographically approved
Lytsy, P., Engström, S., Ekstedt, M., Engström, I., Hansson, L., Ali, L., . . . Berg, J. (2022). Outcomes associated with higher relational continuity in the treatment of persons with asthma or chronic obstructive pulmonary disease: A systematic review. eClinicalMedicine, 49, Article ID 101492.
Open this publication in new window or tab >>Outcomes associated with higher relational continuity in the treatment of persons with asthma or chronic obstructive pulmonary disease: A systematic review
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2022 (English)In: eClinicalMedicine, E-ISSN 2589-5370, Vol. 49, article id 101492Article, review/survey (Refereed) Published
Abstract [en]

Background: Asthma and chronic obstructive pulmonary disease (COPD) are chronic conditions where relational continuity of care, as in regularly meeting the same health care provider, creates opportunities for monitoring and adjustment of treatment based on an individual's changing needs, potentially affecting quality of delivered care. The aim of this systematic review was to investigate the effects of relational continuity in the treatment of persons with asthma or COPD.

Methods: Eleven databases (CINAHL, Medline, PsycINFO, Scopus, Embase, Cochrane Library, Database of Systematic Review of Effects, DARE, Epistemonikos, NICE Evidence Search, KSR Evidence and AHRQ) were searched between January 1, 2000, and February 1 - 4, 2021, for controlled and observational studies about relational continuity and health outcomes for persons with asthma and/or COPD. Inclusion criteria were studies investigating an index or aspect relevant to relational continuity between a health professional/team of health professionals and patients. After screening, and assessment of study relevance and quality by at least two independent reviewers, studies with acceptable risk of bias were included and summary data was extracted from the publications. Main outcomes were mortality, morbidity (including health care utilization) and cost measures. Syntheses without metanalyses were performed due to considerable study heterogeneity. The certainty of the summarized result was assessed using GRADE (the Grading of Recommendations Assessment, Development and Evaluation). PROSPERO study registration number: CRD42020196518.

Findings: We identified 2824 unique references and included 15 studies (14 observational and 1 randomized controlled trial) in the review, from which results were derived for six outcomes. For persons with asthma or COPD we found that higher compared to lower relational continuity of care prevents premature mortality (low certainty; 2 studies, 111 545 participants), lowers risk of emergency department visits (low certainty, 5 studies, 362 305 participates) and risk of hospitalization (moderate certainty, 9 studies, 525 716 participants), and lowers health care costs (low certainty; 4 studies, 390 682 participants). Results regarding treatment adherence (1 study, 971 participants) and patient perceptions (3 studies, 2026 participants) were assessed as having very low certainty.

Interpretation: Low to moderate certainty evidence suggests that higher versus lower relational continuity of care for persons with asthma or COPD prevents premature mortality, lowers risks of unplanned health care utilization and reduces health care costs. The results may be of value when planning care for individuals and for policymakers in organizing health care and developing guidelines for treatment and follow-up routines.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
Asthma, Chronic obstructive pulmonary disease, Continuity of care, Health care utilization, Mortality, Relational continuity
National Category
Public Health, Global Health, Social Medicine and Epidemiology Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:oru:diva-99781 (URN)10.1016/j.eclinm.2022.101492 (DOI)000829737900004 ()35747174 (PubMedID)2-s2.0-85131402524 (Scopus ID)
Available from: 2022-06-28 Created: 2022-06-28 Last updated: 2023-07-13Bibliographically approved
Schückher, F., Berglund, K., Engström, I. & Sellin, T. (2022). Predictors for Abstinence in Socially Stable Women Receiving Treatment for Alcohol Use Disorder. Alcoholism Treatment Quarterly, 40(2), 244-257
Open this publication in new window or tab >>Predictors for Abstinence in Socially Stable Women Receiving Treatment for Alcohol Use Disorder
2022 (English)In: Alcoholism Treatment Quarterly, ISSN 0734-7324, E-ISSN 1544-4538, Vol. 40, no 2, p. 244-257Article in journal (Refereed) Published
Abstract [en]

There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in socially stable women. Fifty-seven women with AUD participated in 12-month follow-up. Information about sociodemographic, alcohol-related, psychiatric symptoms, psychological functioning, and participants' treatment goals and ability to change alcohol habits were gathered from structured interviews and self-report instruments. Predictors for abstinence at the 12-month follow up were calculated by univariable and multivariable logistic regression models. Significant predictors for abstinence were having no history of childhood abuse (OR: 8.13; 95%CI: 2.22-29.75; p < .01) and a goal of abstinence at the end of treatment (OR: 15.17; 95%CI: 3.45-66.69; p < .001). Most participants (>60%) achieved their goals of abstinence or low-risk drinking. The results highlight the significance of identifying patients with experiences of childhood abuse, since such experiences may adversely affect the outcome of AUD treatment. Our findings also emphasize the importance of patients' own goals of abstinence, since it resulted in the most stable outcome. Treatment could, therefore, also focus on motivating individuals to aim for abstinence.

Place, publisher, year, edition, pages
Routledge, 2022
Keywords
Alcohol use disorder, treatment, 12-months follow up, childhood abuse, goal of abstinence, well-adjusted women
National Category
Substance Abuse
Identifiers
urn:nbn:se:oru:diva-96494 (URN)10.1080/07347324.2021.2018957 (DOI)000740609800001 ()2-s2.0-85122706482 (Scopus ID)
Available from: 2022-01-17 Created: 2022-01-17 Last updated: 2022-04-22Bibliographically approved
Lynøe, N., Engström, I. & Juth, N. (2022). Rawlsian reasoning about fairness at the end of life. BMJ Supportive & Palliative Care, Article ID bmjspcare-2021-003500.
Open this publication in new window or tab >>Rawlsian reasoning about fairness at the end of life
2022 (English)In: BMJ Supportive & Palliative Care, ISSN 2045-435X, E-ISSN 2045-4368, article id bmjspcare-2021-003500Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVES: The aim of this study was to discuss end-of-life care in the context of Rawls' and Daniels' philosophy of justice. The study is based on an empirical survey of Swedish physicians who were asked whether they would want the option of physician-assisted suicide (PAS) for themselves (hereafter called own preferences), what are their attitudes towards PAS in general and whether they were prepared to prescribe PAS drugs to eligible patients. The question is to what extent the physicians' answers are impartial and consistent in a Rawlsian sense.

METHODS: The underlying indicator was the physicians' own preferences. Kappa score inter-rater agreement was measured between that response and that same physician's general attitude towards allowing PAS and preparedness to prescribe PAS drugs. The coherence of provided comments and arguments were analysed using content analysis.

RESULTS: Palliative care physicians are the least willing to offer PAS, and surgeons and psychiatrist the most willing. There is a discrepancy between physicians' general attitudes about allowing PAS, their own wishes to be offered PAS at the end of life and the concrete action of prescribing PAS drugs. Arguments given for not prescribing PAS by those in favour of PAS are seemingly but not truly inconsistent.

CONCLUSIONS: Those supporting PAS provided impartial and consistent arguments for their stances in a Rawlsian sense, while those against PAS provided partial arguments. Two specialties, psychiatrists and palliative care physicians, were coherent in their reasoning about PAS for themselves and their willingness to prescribe the needed drugs.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2022
Keywords
End of life care, ethics, hospice care, methodological research, terminal care
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:oru:diva-99874 (URN)10.1136/spcare-2021-003500 (DOI)000819490200001 ()35768205 (PubMedID)2-s2.0-85134584254 (Scopus ID)
Available from: 2022-06-30 Created: 2022-06-30 Last updated: 2023-12-08Bibliographically approved
Lindow, M., Kjellin, L., Engström, I. & Pelto-Piri, V. (2022). Strategies for the Prevention of Violence in Institutional Care: A Qualitative Interview Study With Ward Managers. Frontiers in Psychiatry, 13, Article ID 853260.
Open this publication in new window or tab >>Strategies for the Prevention of Violence in Institutional Care: A Qualitative Interview Study With Ward Managers
2022 (English)In: Frontiers in Psychiatry, E-ISSN 1664-0640, Vol. 13, article id 853260Article in journal (Refereed) Published
Abstract [en]

Background: The presence of violence within psychiatric and residential settings remains a challenge. Research on this problem has often focused on describing violence prevention strategies from either staffs' or service users' perspectives, and the views of ward managers has been largely overlooked. The aim of the present study was therefore to identify ward managers' strategies to prevent violence in institutional care, focusing on safety and values.

Methods: Data were collected using semi-structured interviews with 12 ward managers who headed four different types of psychiatric wards and two special residential homes for adolescents. Qualitative content analysis was applied, first using a deductive approach, in which quotes were selected within a frame of primary, secondary, and tertiary prevention, then by coding using an inductive approach to create themes and subthemes.

Results: Ward managers' strategies were divided into the four following themes: (1) Balancing being an active manager with relying on staff's abilities to carry out their work properly while staying mostly in the background; (2) Promoting value awareness and non-coercive practices in encounters with service users by promoting key values and adopting de-escalation techniques, as well as focusing on staff-service user relationships; (3) Acknowledging and strengthening staff's abilities and competence by viewing and treating staff as a critical resource for good care; and (4) Providing information and support to staff by exchanging information and debriefing them after violent incidents.

Conclusions: Ward managers described ethical challenges surrounding violence and coercive measures. These were often described as practical problems, so there seems to be a need for a development of higher ethical awareness based on a common understanding regarding central ethical values to be respected in coercive care. The ward managers seem to have a high awareness of de-escalation and the work with secondary prevention, however, there is a need to develop the work with primary and tertiary prevention. The service user group or user organizations were not considered as resources in violence prevention, so there is a need to ensure that all stakeholders are active in the process of creating violence prevention strategies.

Place, publisher, year, edition, pages
Frontiers Media S.A., 2022
Keywords
Adolescents, coercive measures, prevention, qualitative content analysis, residential homes, values, violence, ward manager
National Category
Nursing
Identifiers
urn:nbn:se:oru:diva-98788 (URN)10.3389/fpsyt.2022.853260 (DOI)000807657600001 ()35463501 (PubMedID)2-s2.0-85128689674 (Scopus ID)
Available from: 2022-05-04 Created: 2022-05-04 Last updated: 2024-01-17Bibliographically approved
Lynøe, N., Engström, I. & Juth, N. (2021). How to reveal disguised paternalism: version 2.0. BMC Medical Ethics, 22(1), Article ID 170.
Open this publication in new window or tab >>How to reveal disguised paternalism: version 2.0
2021 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 22, no 1, article id 170Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: We aim to further develop an index for detecting disguised paternalism, which might influence physicians' evaluations of whether or not a patient is decision-competent at the end of life. Disguised paternalism can be actualized when physicians transform hard paternalism into soft paternalism by questioning the patient's decision-making competence.

METHODS: A previously presented index, based on a cross-sectional study, was further developed to make it possible to distinguish between high and low degrees of disguised paternalism using the average index of the whole sample. We recalculated the results from a 2007 study for comparison to a new study conducted in 2020. Both studies are about physicians' attitudes towards, and arguments for or against, physician-assisted suicide.

RESULTS: The 2020 study showed that geriatricians, palliativists, and middle-aged physicians (46-60 years old) had indices indicating disguised paternalism, in contrast with the results from the 2007 study, which showed that all specialties (apart from GPs and surgeons) had indices indicating high degrees of disguised paternalism.

CONCLUSIONS: The proposed index for identifying disguised paternalism reflects the attitude of a group towards physician assisted suicide. The indices make it possible to compare the various medical specialties and age groups from the 2007 study with the 2020 study. Because disguised paternalism might have clinical consequences for the rights of competent patients to participate in decision-making, it is important to reveal disguised hard paternalism, which could masquerade as soft paternalism and thereby manifest in practice. Methods for improving measures of disguised paternalism are worthy of further development.

Place, publisher, year, edition, pages
BioMed Central, 2021
Keywords
Disguised paternalism, Hard and soft paternalism, Physician assisted suicide, Value impregnated factual claims
National Category
Medical Ethics
Identifiers
urn:nbn:se:oru:diva-96287 (URN)10.1186/s12910-021-00739-8 (DOI)000734769000002 ()34961487 (PubMedID)2-s2.0-85121676267 (Scopus ID)
Funder
The Karolinska Institutet's Research Foundation
Available from: 2022-01-07 Created: 2022-01-07 Last updated: 2022-01-07Bibliographically approved
Lynøe, N., Lindblad, A., Engström, I., Sandlund, M. & Juth, N. (2021). Trends in Swedish physicians' attitudes towards physician-assisted suicide: a cross-sectional study. BMC Medical Ethics, 22(1), Article ID 86.
Open this publication in new window or tab >>Trends in Swedish physicians' attitudes towards physician-assisted suicide: a cross-sectional study
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2021 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 22, no 1, article id 86Article in journal (Refereed) Published
Abstract [en]

Aims: To examine attitudes towards physician-assisted suicide (PAS) among physicians in Sweden and compare these with the results from a similar cross-sectional study performed in 2007.

Participants: A random selection of 250 physicians from each of six specialties (general practice, geriatrics, internal medicine, oncology, surgery and psychiatry) and all 127 palliative care physicians in Sweden were invited to participate in this study.

Setting: A postal questionnaire commissioned by the Swedish Medical Society in collaboration with Karolinska Institute in Stockholm.

Results: The total response rate was 59.2%. Slightly fewer than half [47.1% (95% CI 43.7-50.5)] of the respondents from the six specialties accepted PAS, which is significantly more than accepted PAS in the 2007 study [34.9% (95% CI 31.5-38.3)]. Thirty-three percent of respondents were prepared to prescribe the needed drugs. When asked what would happen to the respondent's own trust in healthcare, a majority [67.1% (95% CI 63.9-70.3)] stated that legalizing PAS would either not influence their own trust in healthcare, or that their trust would increase. This number is an increase compared to the 2007 survey, when just over half [51.9% (95% CI 48.0-55.2)] indicated that their own trust would either not be influenced, or would increase.

Conclusions: The study reveals a shift towards a more accepting attitude concerning PAS among physicians in Sweden. Only a minority of the respondents stated that they were against PAS, and a considerable proportion reported being prepared to prescribe the needed drugs for patient self-administration if PAS were legalized.

Place, publisher, year, edition, pages
BioMed Central, 2021
Keywords
Physician assisted suicide, Physician attitude, Prescribing drugs, Trust in healthcare, Non-maleficent principle, Autonomy principle
National Category
Medical Ethics
Identifiers
urn:nbn:se:oru:diva-93205 (URN)10.1186/s12910-021-00652-0 (DOI)000669203800001 ()34215231 (PubMedID)2-s2.0-85109143311 (Scopus ID)
Funder
The Karolinska Institutet's Research Foundation
Available from: 2021-07-29 Created: 2021-07-29 Last updated: 2021-08-10Bibliographically approved
Engström, I., Engström, K. & Sellin, T. (2020). Adolescents' Experiences of the Staff's Different Interaction Styles in Coercive Youth Care in Sweden: A Qualitative Study. Issues in Mental Health Nursing, 41(11), 1027-1037
Open this publication in new window or tab >>Adolescents' Experiences of the Staff's Different Interaction Styles in Coercive Youth Care in Sweden: A Qualitative Study
2020 (English)In: Issues in Mental Health Nursing, ISSN 0161-2840, E-ISSN 1096-4673, Vol. 41, no 11, p. 1027-1037Article in journal (Refereed) Published
Abstract [en]

We interviewed 20 adolescents who were coercively placed in residential or psychiatric care. The aim was to explore their views on the way staff relate and perform their duties, favorable characteristics in staff, consequences of different treatment from staff and their safety experiences. Thematic analysis identified the following themes: Situational triggers of frustration; Care-based; rule-based; or passive-avoidant interaction styles toward adolescents and their responses; Adolescents' reflections about staff's interaction styles; and the Consequences on the unit atmosphere depending on different interaction styles toward the adolescents. Adolescents preferred staff who showed them respect and a clear wish to make life easier.

Place, publisher, year, edition, pages
Taylor & Francis, 2020
National Category
Nursing
Identifiers
urn:nbn:se:oru:diva-84271 (URN)10.1080/01612840.2020.1757794 (DOI)000549043200001 ()32585115 (PubMedID)2-s2.0-85087175084 (Scopus ID)
Funder
The Swedish National Board of Institutional Care, SiS, 2.6.1-1132-2015
Available from: 2020-08-26 Created: 2020-08-26 Last updated: 2020-12-08Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-3227-2487

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