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Background: Access to equal health services is a key issue in most European countries. In the coming years, immigrants will constitute an increasing proportion of older adults in Europe, and their need for healthcare services will likely increase. Healthcare services must prepare for such encounters to make them equitable. Older immigrants' hospitalization experiences require elucidation. Their patient experiences can provide important knowledge when the healthcare system is working toward equal and equitable healthcare services., Methods: This study employed an exploratory qualitative design. Data were collected through narrative interviews with a purposive sample of eight older adult immigrants, aged 61-79 years. Patient narratives were analyzed using thematic analysis with a reflexive approach, as outlined by Braun and Clarke., Results: The analysis created three themes that shed light on older adult immigrants' experiences as hospital patients. The themes conveyed experiences related to challenging involvement and interaction, notions of what an ideal patient should be like, and participants not feeling valued as a person., Conclusion: The findings indicate that communication between healthcare professionals and older adult immigrant patients is deficient: older immigrants in this study did not make their voices heard nor were they invited to participate by healthcare professionals. This contributes to limited involvement in assessment, treatment, and care. The older immigrants felt that they were not valued nor met as unique individuals. The findings indicate that health policy goals regarding patient participation and person-centered care are not met when older immigrants are patients. Consequently, the experiences of older adult immigrants in this study indicate that equal health services are at risk., Competing Interests: Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical guidelines of the Declaration of Helsinki [49]. This study was submitted to the Regional Committee for Medical and Health-Related Research Ethics in Mid Norway (No. 2019/988/REK-midt), which assessed and concluded that the project was exempt from the requirements of the Health Research Act [50]. The Norwegian Centre for Research Data (now named SIKT - Norwegian Agency for Shared Services in Education and Research) approved that the processing of personal data complied with personal data legislation in Norway (No. 241115).All participants received written and verbal information regarding the study purpose and were given opportunities to ask questions about anything that was unclear or difficult to understand. It was made clear that participation was voluntary and that they could withdraw from the study at any time, without having to provide a reason. Written informed consent was obtained from all participants prior to the face-to-face interviews. For the telephone interviews, participants had to provide verbal informed consent prior to the interview by answering the following three questions: (i) whether they had received information about the project, (ii) whether the information was understood or if anything was unclear, and (iii) whether they voluntarily agreed to participate in the telephone interview. This was clarified and performed in accordance with guidelines from the Norwegian Centre for Research Data (No. 241115). Participants provided written informed consent following the telephone interviews. Confidentiality was safeguarded throughout the project to protect participants’ personal data. We ensured that encrypted audio recordings, consent forms, and personally identifiable information were kept in a locked cabinet in a locked office, separate from de-identified transcripts. We have been careful with using quotations and have created broad demographic categories, such as age and length of stay in Norway, to minimize the risk of participant identification. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Many cancer patients prefer to receive palliative treatment at home, as it allows them to be in a familiar and comfortable environment. Integrating Advance Care Planning (ACP) into routine practice in primary healthcare helps patients and their relatives prepare for end-of-life (EoL) care in accordance with patients' preferences. This includes the option to spend their final days at home if desired. The aim of this study was to gain insights from experiences of advanced seriously ill cancer patients at home while receiving palliative treatment and being engaged in ACP within primary healthcare settings., Method: This study employed a qualitative design, utilizing individual, semi-structured interviews that were analysed through reflexive thematic analysis, employing an abductive approach with a latent-level focus. The study included interviews with 12 participants with cancer who were receiving palliative care, had an estimated lifetime under 3 months, and had undergone an organized ACP approach in primary healthcare, documented with a palliative plan., Results: Participants emphasized the importance of (1) Preserving normality at home, maintaining a sense of routine, comfort, and familiarity in the face of present and future challenges. The top obstacles for success identified by participants included (1a) The challenge of deterioration and the dual aspects of (1b) The value and burden of family caregivers. Cancer treatment placed a significant demand on patients due to side effects. Family caregivers played a crucial role for participants, providing support in daily life and serving as a key factor in the overall decision to which extend they are able to involve in support and care at home in the future. (2) Compassionate health care personnel (HCP) made a difference by fostering a culture of understanding participants' concerns, fears, and preferences, which was a key element that built and maintained trust for the participants. (3) Preparing for the future, especially EoL discussions initiated by healthcare personnel, was deemed important but, at times, uncomfortable for participants as it confronted them with reality. Guidance from ACP provided them with a sense of certainty and control., Conclusion: Preserving normality at home, along with the desire to stay at home for as long as possible, is a crucial goal for advanced cancer patients. Consistent professional communication and care in primary healthcare play a key role in building and maintaining trust, as well as fostering a sense of certainty and control for the participants., (© 2024. The Author(s).)

Purpose: This study aimed to explore the experiences of patients with advanced cancer with Advanced care planning (ACP) communication and drawing up a palliative plan in primary healthcare settings in Norway., Methods: In this exploratory qualitative study, data were collected using semi-structured interviews with five patients with cancer who had undergone ACP and had a palliative care plan., Results: The result shows three main themes with subthemes; (1) The difficult ACP conversation about cancer and death was tough, painful, and considered a "taboo." The patients wished they had been prepared for the conversation and had it in their own homes. (2) Interactions with the doctor/nurse about the palliative care plan helped the patients feel valued and involved and brought their wishes into focus. The next of kin was present but not involved in the process. (3) Having a palliative plan was meaningful for the patients; they felt safe, and it gave them a sense of security., Conclusions: Patients with advanced cancer in a home setting in Norway experienced ACP for the preparation of a palliative plan as a process from difficulty to meaning. In this process, the context and interactions provided by the doctor/nurse and their competency in communicating with the patients and involving them as persons was important. The palliative plan gave the patients a sense of meaning, control, and safety connected to the time for the end of life., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

We compared online distributed information provided to patients with cancer in Scandinavian countries through the lens of governmentality. A secondary comparative qualitative analysis was conducted. Discourses in online patient information showed differences in governmentality techniques across the countries: Norway used a paternalist approach, Denmark an educative approach, and Sweden an individualistic approach and expected the patients to make the "right" decisions. Online information for patients with cancer in Denmark and Norway showed high professional and health care system involvement, whereas in Sweden, there was high patient involvement. There was almost no use of the person-centered approach among the online discourses., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The immigrant population across Europe is ageing rapidly. Nurses will likely encounter an increasing number of patients who are older adult immigrants. Moreover, access to and equal provision of healthcare is a key issue for several European countries. The relationship between nurses and patients is asymmetrical with unequal power relations; however, the way nurses construct the patient through language and discourse can help maintain or change the balance of power. Unequal power relations can affect access and be a hindrance to equal healthcare delivery. Hence, the aim of this study is to explore how older adult immigrants are discursively constructed as patients by nurses., Methods: An exploratory qualitative design was used. Data were collected through in-depth interviews with a purposive sample of eight nurses from two hospitals. The nurses' narratives were analysed using critical discourse analysis (CDA) as described by Fairclough., Results: The analysis identified an overarching, stable, and dominant discursive practice; 'The discourse of the other', with three interdiscursive practices: (1) 'The discourse on the immigrant patient versus an ideal patient'; (2) 'The expert discourse'; and (3) 'The discourse of adaption'. Older immigrant adults were constructed as 'othered' patients, they were different, alienated, and 'they' were not like 'us'., Conclusion: The way nurses construct older adult immigrants as patients can be an obstacle to equitable health care. The discursive practice indicates a social practice in which paternalism overrides the patient's autonomy and generalization is more prevalent than a person-centred approach. Furthermore, the discursive practice points to a social practice wherein the nurses' norms form the basis for normal; normality is presumed and desirable. Older adult immigrants do not conform to these norms; hence, they are constructed as 'othered', have limited agency, and may be considered rather powerless as patients. However, there are some examples of negotiated power relations where more power is transferred to the patient. The discourse of adaptation refers to a social practice in which nurses challenge their own existing norms to best adapt a caring relationship to the patient's wishes., (© 2023. The Author(s).)

During preparation for early abortion in Norway, an ultrasound examination is usually performed to determine gestation and viability. This article aims to provide a deeper understanding of women's and health care personnel's (HCP) experiences with ultrasound viewing during abortion preparation in the first trimester. Qualitative in-depth interviews with women who had been prepared for early abortion and focus group interviews with HCP from gynaecological units were carried out. A hermeneutic-phenomenological analysis, inspired by van Manen, was chosen. Thirteen women who were pregnant and considering abortion in their first trimester and 20 HCP, namely, 19 registered nurses and one medical doctor, were recruited from gynaecological units at six hospitals. The study was approved by the ethics committee (2014/1276). The essential meaning structure of 'autonomy under pressure' consisted of two themes that expressed the different experiences of both the women and the HCP, namely, expectations versus precautions and choice versus protection. The women and HCP expressed different attitudes before the consultation that affected their experiences of the ultrasound examination. While the women had expectations of a clarification based on their choice to either see or not see the ultrasound image, HCP seemed to be more concerned with predetermined rules that they believed would protect the women. Consequently, the basis for dialogue was not optimal, and women's autonomy was under pressure. Health care personnel are ethically challenged during preabortion ultrasound examinations. Meeting the individual woman's needs and respecting her autonomy during preparation for abortion requires sensitivity, involvement, and dialogue skills by health personnel. According to the woman's desire to be informed about the possibility of viewing the image during the abortion preparations, a dialogue that is focused in this direction should arise before the examination.

Aims and Objectives: The present study aimed to explore patients' experiences of participating in their rehabilitation process in the context of specialised rehabilitation in Norway., Background: The rights of patients to participate in their care and treatment is an ideology that underlines newer international and Norwegian public documents. However, there is a gap between policy statements and clinical practice, and a discrepancy between patients' and professionals' statements about patient participation in rehabilitation., Design: A qualitative approach with a narrative design., Methods: Eleven patients were individually interviewed to tell their stories about the rehabilitation processes. We utilised narrative analysis with a three-dimensional space narrative structure including temporality, sociality and spatiality. This study followed the COREQ checklist., Results: The analysis identified two throughout plots: 'person-centred culture' and 'time', and three plots which constructed how the patients participate in change through the rehabilitation process: (a) dependent-'open doors'; (b) motivation from within; and (c) independence-'locked doors'., Conclusions: Patient participation in rehabilitation was dependent on person-centred cultures in the unit and on different aspects of time. The dialogue and the power balance between the patients and the health personnel changed as the rehabilitation progressed. Motivation for rehabilitation had to come from within patients. The paternalistic ideology did not seem to dominate the specialised rehabilitation unit in the present study., Relevance to Clinical Practice: This study gives new insight into how patients participate in change in the rehabilitation process. This can be valuable for healthcare professionals and governments. Insight into how the lack of person-centred focus can harm the rehabilitation process, and a deeper understanding of the meaning of time in the rehabilitation process is essential. These results may provide a stimulus for discussions on how patients might participate in their rehabilitation process., (© 2021 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Background: User participation is an important aspect of nursing, especially within a rehabilitation setting where the emphasis is on the patient's ability to become as independent as possible. It is also decreed by law that students should learn about user participation. Furthermore, to achieve good nursing skills it is important for the students to understand "the what" and to reflect on "the how" regarding user participation., Objectives: The aim of the study was to explore how students learn to apply user participation in a context of rehabilitation., Design and Method: The design of the study is qualitative. Content analysis was adopted, and both inductive and deductive approaches were used. The informants were nursing students in the second and third years of the bachelor's degree at a university in Norway. Most of the students were in community health services, but some of them performed their internship at hospitals. Two focus groups with 11 students were conducted. In addition, the data also consist of 28 written reflections and 31 written work requirements in relation to rehabilitation. The students from the focus groups and the written work requirement were in practice in community health services. In the written reflections it was 14 students who had their internship at hospital and 14 students in community health services., Results: The main categories of the study are barriers to learning, dialogue as a tool and reflection as essential. The students learn to use check lists and focus on organizational planning, which might be a barrier to learning. Dialogue is important to improve the students' learning. Students need to reflect on user participation together with their supervisor to learn to be confident in encountering users, which indicates that reflection is essential., Conclusion: The major findings indicate that students lack competence og user participation and that their supervisors seldom talk about it with them. Also, it should be compulsory reflection notes about user participation in the student's internships. Teachers at universities must inform supervisors and develop courses about mentorship and user participation. This may be a step forward to overcome theory-practice gap., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Aim: To explore how the patient is constructed and socially positioned in discourses of web-based pathways information available to people with cancer in Norway., Design: Mixed qualitative and quantitative design, using Corpus-Assisted Critical Discourse Analysis., Methods: The study, conducted in January 2020, examined the language of one general and six specific web-based cancer pathways information brochures. The approach combines analysis of word frequencies and concordance lines using corpus analysis software to identify the 'linguistic fingerprint' or 'aboutness' of the text prior to further qualitative critical discourse analysis., Results: The analysis identified three core discourses which constructed the patient differently: (a) a participating active person, in a brief, inclusive discourse; (b) a passive person lacking knowledge or perception of their situation in dominant, medical and interprofessional expert discourse; and (c) reduced to a disease and a code in the pathways discourse., Conclusion: This study offers insight into the construction of patients in online clinical pathways information for cancer treatment. The analysis revealed how governance systems such as New Public Management and its demands on efficiency and productivity influence the cancer pathways. The World Health Organization has promoted a person-centred approach, emphasizing the importance of participation and a partnership of equals. A person-centred approach to care was not evident in the discourse of the online documents. The dominant ideology of these pathways was paternalistic with patients constructed as passive persons who get standardized treatment., Impact: This study gives new insight that can be valuable for nurses, other healthcare professionals and the government. The lack of a person-centred focus in the cancer pathway information could have a negative impact on the patient's health outcomes by promoting a culture of inattention to the patients' needs and wishes among practitioners. The results may provide a stimulus for discussion about the role of patients in cancer treatment., (© 2020 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

The factors affecting long-term biofilm stability in sewage treatment remain largely unexplored. We therefore analyzed moving bed bioreactors (MBBRs) biofilm composition and function two years apart from four reactors in a nitrogen-removal sewage treatment plant. Multivariate ANOVA revealed a similar prokaryote microbiota composition on biofilm carriers from the same reactors, where reactor explained 84.6% of the variance, and year only explained 1.5%. Eukaryotes showed a less similar composition with reactor explaining 56.8% of the variance and year 9.4%. Downstream effects were also more pronounced for eukaryotes than prokaryotes. For prokaryotes, carbon source emerged as a potential factor for deterministic assembly. In the two reactors with methanol as a carbon source, the bacterial genus Methylotenera dominated, with M. versatilis as the most abundant species. M. versatilis showed large lineage diversity. The lineages mainly differed with respect to potential terminal electron acceptor usage (nitrogen oxides and oxygen). Searches in the Sequence Read Archive (SRA) database indicate a global distribution of the M. versatilis strains, with methane-containing sediments as the main habitat. Taken together, our results support long-term prokaryote biofilm persistence, while eukaryotes were less persistent.

Background: While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women's experiences with these encounters have rarely been examined., Objective: The objective of this study was to explore ambivalent abortion-seeking women's experiences of their encounters with health personnel., Research Design: The data were collected in individual interviews and analysed with dialogical narrative analyses., Participants and Research Context: A total of 13 women (aged 18-36 years), who were uncertain of whether to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics., Ethical Considerations: Approval was granted by the Regional Committee for Medical and Health Research Ethics., Findings: The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women's experiences with encounters with health personnel were identified: the respected women; the identified women; and the abandoned women., Discussion: The findings are discussed in terms of the ambivalent pregnant woman's autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel., Conclusion and Implication: Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women's values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence.

Background: Since the adoption of the Universal Declaration of Human Rights by the United Nations in 1948, human rights as set out in government documents have gradually changed, with more and more power being transferred to individual., Objectives: The aim of this article is to analyze how the position of the patient in need of care is constructed in Norway's renamed and revised Patients' and Service Users' Rights Act (originally Patients' Rights Act, 1999) and published comments which accompanying this legislation from the Norwegian Ministry of Health and Care Service., Research Design: A constructivist design was used, and Fairclough's critical discourse approach was adopted to analyze the text of the Patients' and Service Users' Rights Act and comments., Findings: The analysis identified three discourses: (a) political discourse, containing ethical discourses about priority and economy, in which patients are constructed as powerless individuals; (b) expert discourse, containing a theme about patients' trust in the healthcare team and its knowledge, in which patients are constructed as helpless individuals lacking knowledge; and (c) patient participation and patient autonomy discourse, containing ethical discourses about decision-making, in which patients are constructed not only as individuals with needs and rights but also as "troublesome.", Conclusion: Dominant paternalistic discourses in the legal text validate the power of medicine, the healthcare system, and heath personnel over the needs, rights, participation, and autonomy of the patient.

Aims and Objectives: To improve the understanding and competence of health personnel when caring for ambivalent pregnant women, the aim of this study was to explore the experiences of encountering women who are unsure whether to complete or terminate pregnancy., Background: Feelings of ambivalence are present in a significant number of women preparing for abortions and may challenge the provision of health care. Health personnel have reported an ideal to be nonjudgemental and supportive. Insufficient attention has been directed to the experiences of health personnel who prepare women for abortions in gynaecological units., Design: Qualitative design with a hermeneutic-phenomenological approach., Methods: Focus group interviews were conducted with health personnel from four gynaecological outpatient clinics and wards in Norway (n = 20)., Results: The health personnel felt responsible for contributing to patient well-being. This demanded focused attention towards all women being prepared for abortions and meant a consciousness and balancing act towards revealing, handling and being involved in the woman's potential unsureness without influencing her decision. When involved, the health personnel risked being confronted with their own vulnerabilities and values., Conclusions: The health personnel tried to balance their care and support without influencing the woman's decision. Although they viewed the women as fully autonomous and responsible, they became personally involved, to varying degrees, in the uncertainty and were faced with their own vulnerabilities and values. They lacked a possibility for immediate debriefing and regular counselling after complicated consultations., Relevance to Clinical Practice: Knowledge of the experiences of health personnel can provide input for professional development at gynaecological departments. These findings contribute to discussions about what information should be given and whether the woman's feelings should be discussed in preparation for an abortion. The ability of health personnel to discuss subjects related to ethically challenging encounters with women who are considering abortions should be established, namely, professional education and workshops at the national level and small groups with counselling and case study discussions at hospitals., (© 2018 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.)

Abortion during the first trimester is legal in most Western countries. However, deciding to terminate a pregnancy is a challenging process, and some women arrive at the abortion clinic still not absolutely certain. We explored the experiences of 13 pregnant Norwegian women struggling to finalize their decision, interviewing them before and after their decision. Verification of the pregnancy meant a new reality for the women. They started to consider their readiness, describing the experience as a lonely journey during which their values were challenged. A feeling of existential loneliness dominated the decision-making process and the implementation.

Background: According to Norwegian law, nurses are obligated to provide an acceptable level of health assistance to patients and their family members and to allow patients and their family members to participate in the planning of patient care and treatment., Aim: The aim of this study is to compare the perceptions of older patients undergoing haemodialysis treatment and of their next of kin and of nurses regarding patient participation in the context of haemodialysis treatment., Research Design: The study adopts an approach that is both comparative and explorative in nature by examining the narratives of patients, nurses and next of kin and by performing critical discourse analysis as outlined by Fairclough., Ethical Considerations: Permission to carry out the research was granted by the Regional Committee for Medical and Health Research Ethics of Mid-Norway and by the participating hospitals. Informed consent and confidentiality were ensured., Findings: Two discourses were found: (a) the discourse of paternalism with the discursive practices of achieving physiological balance in patients, trusting the healthcare team and being excluded or included in the difficult end-of-life decision-making process, and (b) the discourse of patient participation, with the themes of maintaining patients' quality of life and trusting patients., Conclusion: The participation of older patients and their next of kin was not as well integrated as social practice in dialysis units. The dominant discourse seemed to have an ideology and social practice of paternalism. However, there existed hegemonic struggles for an ideology of patient participation that involved (a) achieving physiological balance in patients versus maintaining patients' quality of life, (b) trusting the healthcare team versus trusting the patient, and (c) being excluded versus included in the difficult end-of-life decision-making process., (© The Author(s) 2014.)

Aim: This paper is a report of a study conducted to explore how the family members of older people who will undergo haemodialysis treatment for the rest of their lives perceive participation., Background: The rights of families to participate in treatment and health care are supported by international law, and by national law in Norway since 1999., Method: This study, which employed an explorative qualitative approach, was carried out in Norway in 2008. Data were derived from transcribed interviews with seven family members underwent critical discourse analysis., Findings: Three discourse practices about the next of kin perception of participation were found: (1) to care and take control, (2) to struggle for involvement, and (3) to be forgotten and powerless. The next of kin said that they had no dialogue with the healthcare team, and some fought to be included in the decision-making process., Conclusion: The dominant part of the discourse as expressed by the next of kin seems to be a paternalistic ideology. Thus, finding ways to enable the next of kin to participate in the decision-making process seems to be a major challenge for the healthcare team in the dialysis units., (© 2011 Blackwell Publishing Ltd.)

The aim of this study is to explore how nurses perceive patient participations of patients over 75 years old undergoing hemodialysis treatment in dialysis units, and of their next of kin. Ten nurses told stories about what happened in the dialysis units. These stories were analyzed with critical discourse analysis. Three discursive practices are found: (1) the nurses' power and control; (2) sharing power with the patient; and (3) transferring power to the next of kin. The first and the predominant discursive practice can be explained with an ideology of paternalism, in which the nurses used biomedical explanations and the ethical principle of benefice to justify their actions. The second can be explained with an ideology of participation, in which the nurses used ethical narratives as a way to let the patients participate in the treatment. The third seemed to involve autonomous decision-making and the ethical principle of autonomy for the next of kin in the difficult end-of-life decisions.

Aim: A patient's right to influence treatment and health care has been guaranteed by Norwegian law since 1999. The aim of this study was to explore how elderly patients with end-stage renal disease who are undergoing treatment with haemodialysis for the rest of their lives perceive patient participation in a dialysis unit., Methods: This study, which was inspired by critical discourse analysis, drew on data derived from transcribed interviews with 11 patients., Findings: Two discourses related to patient participation were identified. The first and dominant discourse was called the health-care team's power and dominance. Both environmental conditions and the team's practice exercised power and control over the patients. The patients trusted the health-care team, but some felt powerless and were afraid of what might happen if they refused to follow the instructions. The health-care team owned the knowledge and decided what the patients needed to know. Most of all the patients wanted dialogue about the future. After years of treatment, patient identity seemed to be threatened by this situation. The second discourse is called the patients struggling for shared decision-making. Some patients struggled to be involved in decision-making about 'dry weight', diet, blood access and time of treatment when these factors threatened their well-being and the quality of their daily lives., Conclusions: The elderly patients' right to participate in their haemodialysis treatment did not seem to be well incorporated into the social practices of haemodialysis units. Changing the social practices in the dialysis units from a paternalistic ideology to an ideology of participation will require consideration of the context, the dialogue and the process of shared decision-making with the patient., (© 2011 The Authors. Scandinavian Journal of Caring Sciences © 2011 Nordic College of Caring Science.)