PreHospen – prescribing early care

From hospital transport to critical assessment unit; ambulance care requires completely different skills today, in medicine as well as knowledge in caring science, than a few decades ago. Region Västra Götaland realised this in 1999 and established PreHospen at the University of Borås as a regional centre for prehospital care. Today, it is one of six centres at the university.

“Back then, the stated goal was to strengthen the vocational skills and competences in ambulance staff, and give this large group of ambulance nurses a university education. The research has then progressed successively over the years”, Birgitta Wireklint Sundström says, docent in caring science and director of PreHospen.

Birgitta was there from the start and over the last two decades, she has seen how PreHospen has turned into a hub for developing ambulance care in Sweden. Ambulance calls have increased successively, during 2010-2015 by almost 30 per cent. At the same time, emergency care in hospitals was cut down and specialised, which means that the ambulance nurses’ responsibility increased.   

“Ambulance care was always less of a priority, always the step after hospital care when it came to research and education. It was the janitors who started driving the ambulances. Since then, it has been assumed that things will just work out outside the door. But it does not happen by itself”, she says.

Birgitta started her career as a nurse anaesthetist in the mid-1970s. At that time, there was no specific education in prehospital care, and nurses from the anaesthesia clinic took turns staffing the helicopter when severely ill patients were transported to specialist clinics. One particular trip has etched into her mind. It was when she was alone with a sedated child in a helicopter between Umeå and Uppsala. The child was only a few years old and had difficulties with the airways.


You are so vulnerable and exposed in situations like that.

“I still have nightmares about that trip”, she says. “I remember how lonely and unprepared I felt. As a nurse, you are so vulnerable and exposed in situations like that.”

The child survived the transport, but not much longer.

“That really got me, and it was one of all the experiences that made me want to develop prehospital care. Today, there are nurses who only work with missions like that and who are much better prepared. But it is so paradoxical that you are still alone out there where the resources are limited, but there are much more people in the hospitals where the resources are much better.

PreHospen’s research is as wide as it is deep. Research in cardiac arrest has been one of the corner stones from the start, with Johan Herlitz (now professor emeritus) as its hub. Johan was one of the starters of the national quality register called the Swedish Cardiac Arrest Register, which collects data from all cases of cardiac arrest in Sweden, and a lot of the research carried out at PreHospen goes into the Swedish guidelines for cardiopulmonary resuscitation.

In total, the research team at PreHospen has supervised seven nurses to their PhD: s, and in the future they are expected to become many more.

“We would love to collaborate with the healthcare even more, but unfortunately they do not know what do with a nurse with a PhD”, Birgitta Wireklint Sundström says.

One of PreHospen’s strength in recent years is the work in assessment and decision-making. Birgitta Wireklint Sundström defended her doctoral thesis in 2005, titled “Prepared to be unprepared. A phenomenological study of assessment with a caring approach and how it can be learned in the ambulance services”, where she was one of the first researchers internationally to approach the ambulance staff’s work as care and not only medical assessment. In 2011, Magnus Andersson Hagiwara, senior lecturer in caring science and also director of PreHospen, continued on this track. Magnus has a background as an ambulance nurse and still drives an ambulance in the summer. He devotes the rest of the year to being a researcher at PreHospen.


All ambulances have a physical binder with assessment advice. It is 272 pages, without the index. I know few people who use it.

The ambulance staff’s
assessments are crucial for whether the patient should stay home doing self-care, visit a clinic, get a direct transport to examination and treatment, or go to the emergency room. Taking the road via the emergency room is often rationalised away these days.

“All ambulances have a physical binder with assessment advice”, Magnus Andersson Hagiwara says. “It is 272 pages, without the index. I know few people who use it.”

In his dissertation defended in 2014, Magnus developed a computerised assessment system. Parts of that system are now being used in ambulances in England, even though it is further developed.

“The system I developed is not used in Sweden. In some regions there are other digital systems, but in the Västra Götaland region the binder is still used.”

Magnus believes it takes a long time implementing research in the field, and that both eHealth and digitalisation takes a long time in the county councils due to public procurements processes et cetera.

“But there is work going on about procuring IT systems in the Västra Götaland region, where I have been involved in my role as a researcher”, Magnus Andersson Hagiwara says.

Military care is also covered by PreHospen’s research. Kristina Lundberg, doctoral student in caring science at the University of Borås and Jönköping University, is finishing her thesis on ethics among licensed healthcare professionals in the Swedish Armed Forces. Physicians and nurses follow ethic codes about helping all people and not cause harm. In a military context, these ethics codes may come in conflict with tasks of the Swedish Armed Forces. If it is needed to kill another human being, this may cause ethical conflicts.

In the US and UK, the ethical discussion about military medical staff’s role has grown since the war against terrorism broke out after September 11, 2001, when physicians participated in interrogations with methods bordering on torture. According to Kristina Lundberg, the ethical dilemmas in the Swedish Armed Forces are of a different nature, but can be even harder to handle since the boundaries are unclear.

“Basically, this is about where the boundaries are between what medical staff can and should do”, she says. “As a nurse or a physician, your mission is to relieve pain and suffering, treat diseases, and save lives. At the same time, you are a part of the Swedish Armed Forces, exercising on how to take human lives. Here, two professions with diametrically different tasks are to cooperate, which is not the easiest thing to handle”, Kristina Lundberg points out.

Especially if you consider the loyalty that emerges between two people who are out on the same mission, this is a complicated issue.

“According to the law of nations, certified healthcare professionals should not stand guard and not make the first shot”, she says. “They are allowed to help and care for the civilians, but what happens if they tell things that could be used as military intelligence? The boundaries are unclear, and as an only medic it is not easy standing up against a military commander.”

With a background as battalion chaplain in Kosovo and Afghanistan, Kristina Lundberg has interviewed medics as well as officers about their experiences from the field. Her dissertation also contains a philosophical, reasoning part about the role of the medical staff and the law of nations in terms of modern warfare, as well as a chapter where medical staff discuss ethical dilemmas for healthcare professionals – and not only for those in combat zones.

“If it is something that the Swedish Armed Forces is good at, it is training their soldiers in advance, which means that they do not have to deal with ethical considerations when they end up in an emergency. If you are in a stressed situation, you do what you have been trained to do. But all of those who work in a prehospital environment run into ethical problems, sooner or later. The healthcare staff should receive more training and experience in ethical problems before they are exposed to them in the field.”


But all of those who work in a prehospital environment run into ethical problems, sooner or later. 

For almost two decades
now, PreHospen has been working on profiling prehospital care through research and education. They are also engaged in the national discussion and write opinion pieces when needed, for example about the need of more trained ambulance nurses.

Another major issue is the lack of national coordination in ambulance care. The treatment guidelines vary too much between county councils.  The research team sits in the university’s old brick building in Borås, have ten full-time employees and sees themselves as leading in the Nordic countries in their field. The ambition is that soon, everyone should know that too.

PreHospen – Centre for Prehospital Research 

PreHospen – Centre for Prehospital Research at the University of Borås aims at increasing knowledge in prehospital care. PreHospen conducts interdisciplinary research in national and international collaboration, integrating caring science, medical science, medical technology, and informatics in emergency centres, ambulance care, emergency care units, primary care, and municipal health care.

PreHospen was founded in 1999 and a centre since 2015. Arranges a yearly research symposium on prehospital emergency care; one full day where current projects are presented by researchers, doctoral students, and master students, mainly from the Västra Götaland region. Next symposium is March 8, 2018.

“As with most research, we are not so good at reaching out”, says director Magnus Andersson Hagiwara.

The goal is that in a few years, PreHospen should be the obvious reference when it comes to prehospital care and the ones to call.

“Yes, we will lead the development”, Birgitta Wireklint Sundström says. “The increase in skills in ambulance care is impressive compared to when we started 18 years ago, but considering the nursing shortage we cannot take anything for granted.” Birgitta is 65 years old and about to step down before her retirement in a year but shows no signs of slowing down yet.

“It just crawls all over me. You have to keep on fighting”, she says. “When I worked as a nurse anaesthetist in the 1970s, I remember feeling trapped in the operating room. Here at PreHospen, there are so many possibilities. I want to keep pushing the development forward. And competence and early assessments will become even more important over the years. PreHospen is right in the middle of society. We are always there where people need us the most.” 

FOOTNOTE Ambulance nurses are registered nurses with specialist training in emergency care.

Read more

About PreHospen

About Birgitta Wireklint Sundström.

About Magnus Andersson Hagiwara.

Text Christian Naumanen
Photo Suss Wilén