Patient autonomy in home care: Nurses' relational practices of responsibility

A hybrid systematic narrative review of instruments measuring home-based care nurses' competency

AIM

The aim of the study was to identify and synthesize the contents and the psychometric properties of the existing instruments measuring home-based care (HBC) nurses' competencies.

DESIGN

A hybrid systematic narrative review was performed.

REVIEW METHODS

The eligible studies were reviewed to identify the competencies measured by the instruments for HBC nurses. The psychometric properties of instruments in development and psychometric testing design studies were also examined. The methodological quality of the studies was evaluated using the Medical Education Research Study Quality Instrument and COSMIN checklist accordingly.

DATA SOURCES

Relevant studies were searched on CINAHL, MEDLINE (via PubMed), EMBASE, PsychINFO and Scopus from 2000 to 2022. The search was limited to full-text items in the English language.

RESULTS

A total of 23 studies reporting 24 instruments were included. 12 instruments were adopted or modified by the studies while the other 12 were developed and psychometrically tested by the studies. None of the instruments encompassed all of the 10 home-based nursing care competencies identified in an earlier study. The two most frequently measured competencies were the management of health conditions, and critical thinking and problem-solving skills, while the two least measured competencies were quality and safety, and technological literacy. The content and structural validity of most instruments were inadequate since the adopted instruments were not initially designed or tested among HBC nurses.

CONCLUSION

This review provides a consolidation of existing instruments that were used to assess HBC nurses' competencies. The instruments were generally not comprehensive, and the content and structural validity were limited. Nonetheless, the domains, items and approaches to instrument development could be adopted to develop and test a comprehensive competency instrument for home-based nursing care practice in the future.

IMPACT

This review consolidated instruments used to measure home-based care nurses' competency. The instruments were often designed for ward-based care nurses hence a comprehensive and validated home-based nursing care competency instrument is needed. Nurses, researchers and nursing leaders could consider the competency instruments identified in this review to measure nurses' competencies, while a home-based nursing care competency scale is being developed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was required in this review.

First-line managers struggling to lead home care based on the individual's needs and goals - conflict between ethical principles

PURPOSE

The purpose of this paper is to describe how first-line managers (FLMs) in home care (HC) reason about the opportunities and obstacles to lead the work according to the individual's needs and goals.

DESIGN/METHODOLOGY/APPROACH

In this participatory appreciative action reflection project, eight managers within one Swedish municipality were interviewed. The data were analysed using a thematic analysis.

FINDINGS

The results showed a polarization between two different systems that FLMs struggle to balance when attempting to lead HC that adapts to the needs and goals of individuals. One system was represented by the possibilities of a humane system, with human capital in the form of the individual, older persons and the co-workers in HC. The second system was represented by obstacles in the form of the economic needs of the organization in which the individual receiving HC often felt forgotten. In this system, the organization's needs and goals governed, with FLMs needing to adapt to the cost-effectiveness principle and keep a balanced budget. The managers had to balance an ethical conflict of values between the human value and needs-solidarity principles, with that of the cost-effectiveness principle.

ORIGINALITY/VALUE

The FLMs lack the opportunity to lead HC according to the needs and goals of the individuals receiving HC. There is a need for consensus and a value-based leadership model based on ethical principles such as the principles of human value and needs-solidarity to lead the HC according to the individual's needs and goals.

Blurred lines: Ethical challenges related to autonomy in home-based care

BACKGROUND

Home-based care workers mainly work alone in the patient's home. They encounter a diverse patient population with complex health issues. This inevitably leads to several ethical challenges.

AIM

The aim is to gain insight into ethical challenges related to patient autonomy in home-based care and how home-based care staff handle such challenges.

RESEARCH DESIGN

The study is based on a 9-month fieldwork, including participant observation and interviews in home-based care. Data were analysed with a thematic analysis approach.

PARTICIPANTS AND RESEARCH CONTEXT

The study took place within home-based care in three municipalities in Eastern Norway, with six staff members as key informants.

ETHICAL CONSIDERATIONS

The Norwegian Agency for Shared Services in Education and Research evaluated the study. All participants were competent to consent and signed an informed consent form.

FINDINGS

A main challenge was that staff found it difficult to respect the patient's autonomy while at the same time practicing appropriate care. We found two main themes: Autonomy and risk in tension; and strategies to balance autonomy and risk. These were explicated in four sub-themes: Refusing and resisting care; when choosing to live at home becomes risky; sweet-talking and coaxing; and building trust over time. Staff's threshold for considering the use of coercion appeared to be high.

CONCLUSIONS

Arguably, home-based care staff need improved knowledge of coercion and the legislation regulating it. There is also a need for arenas for ethics reflection and building of competence in balancing ethical values in recurrent ethical problems.

Effect of robot for medication management on home care professionals' use of working time in older people's home care: a non-randomized controlled clinical trial

BACKGROUND

Medication management has a key role in the daily tasks of home care professionals delivered to older clients in home care. The aim of this study was to examine the effect of using a robot for medication management on home care professionals´ use of working time.

METHODS

A pragmatic non-randomized controlled clinical trial was conducted. The participants were home care professionals who carried out home care clients' medication management. Home care clients were allocated into intervention groups (IG) and control groups (CG) (n = 64 and 46, respectively) based on whether or not they received the robot. Data were collected using the Working Time Tracking Form prior to and 1 and 2 months after introducing the intervention. The t-test was used to compare the groups at each three timepoints. Analysis of Covariance was used to examine the groups' differences for the total time for medications as the number of visits per day as the covariate.

RESULTS

With robot use, the total amount of home visits decreased by 89.4% and 92.4% after 1 and 2 months of intervention use, respectively, compared to pre-intervention (p < 0.001). The total working time used for medication management considering the number of visits per day decreased from 54.2 min (95% CI 37.4-44.3) to 34.9 min (31.4-38.3), i.e., by slightly over 19 min (p < 0.001) in the IG group. During the follow-up, the total working time used for medication management considering the number of visits per day remained the same in the CG group.

CONCLUSION

Using a robot for medication management had a notable effect on decreasing the use of working time of home care professionals. For health services, decreased use of working time for medication management means that the time saved can be assigned to services that cannot be replaced otherwise. More digital solutions should be developed based on home care clients' and professionals' needs to meet the challenge of the growing number of older people in need of home care and ensure their safety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05908604 retrospectively registered (18/06/2023).

How older adults with physical impairments maintain their autonomy in nursing homes

Autonomy is important to persons, including when they are living in nursing homes. Especially the relational dimension of autonomy is crucial for older adults with physical impairments. They generally have the decisional capacity to make choices about how they want to live their lives, but are often unable, or only partially able, to exercise these decisions themselves. To execute decisions, older adults are dependent on those who support them or care for them. However, little is known about how nursing home residents maintain autonomy in daily life and how others are involved in the decisions and execution of the decisions. To examine how older adults with physical impairments living in nursing homes maintain autonomy in daily life, shadowing, a non-participative observational method, was used. Seventeen older adults were shadowed during the course of one day. The observation ended with a brief interview. After the shadowing, the detailed observation notes were typed out, combined with the verbatim transcript resulting in one extensive report per shadowee. All 17 reports were coded and analysed thematically. Six elements for how older adults maintain autonomy in relation with others were identified, i.e. ‘being able to decide and/or execute decisions’, ‘active involvement’, ‘transferring autonomy to others’, ‘using preferred spaces’, ‘choosing how to spend time in daily life’ and ‘deciding about important subjects’. For all six elements established in this study, it was found that older adults with physical impairments living in nursing homes could only maintain autonomy in daily life when others, such as staff, family and friends, were responsive to signals of the needs of older adults.

Older home care clients' experiences of digitalisation: A qualitative study of experiences of the use of robot for medicines management

BACKGROUND

Home-living older people with multiple medications are a key target group for medication robots. However, our understanding of how robots for medicines management work in older people's daily lives is limited.

AIM

The aim of this study was to describe older home care clients' experiences of the implementation and use of a robot for medicines management at home.

DESIGN

A qualitative interview study.

METHODS

Data were collected during spring and autumn 2021 using semi-structured individual interviews with older home care clients (n = 38). The data were analysed using inductive content analysis.

RESULTS

The older home care clients had positive experiences with the use of technology for the medication process, but they also faced challenges in their daily life activities. Implementation and use of the robot required open-mindedness, satisfaction with the implementation, and the opportunity to practice the use of the robot with a nurse. However, the current design and size of the robot for medicines management in home care still need development, given that our research participants did not feel included in the robot development process.

CONCLUSION

The use of digital solutions will increase older people's home care. Therefore, there is a need to deepen our understanding of the implementation and use of digital solutions to prevent digital challenges and to provide a more comprehensive picture of this phenomenon. In addition, research focusing on whether the use of the robot affects medication administration incidents and medication adherence should be conducted to improve the safety of medicines management.

Concept of older person autonomy: phenomenological study of the opinion of specialist nurses

Background: The concept of autonomy is composed of several components, making it a multidimensional concept. This includes cognitive ability, intellectual ability, emotional intelligence, social situation, and physical ability skills. This study aimed to describe the experiences attributed to the meaning of the concept of autonomy, by specialist nurses. Methods: A descriptive phenomenological study was carried out, according to the Giorgi method. Eighteen nurses were recruited at a hospital in Portugal. Data were collected through individual interviews. Results: The 18 specialist nurses work on average as nurses for 16years and are specialist nurses; for an average of 5.9years, most are specialist nurses in rehabilitation nursing. From the data analysis, six themes emerged: ability to do, ability to resolve, decision ability, cognitive ability, social integration, and emotional intelligence. Conclusions: Most professionals perceive the concept as the ability to perform activities of daily living and the ability to make decisions, especially concerning informed consent. It is necessary to raise awareness of the breadth of this concept since the quality of life and dignity of the elderly person depends on autonomy.

"God Hey, Now I've Been Through Something": Moral Resilience of Coordinators in Voluntary Palliative Terminal Care

Moral distress arises in the dynamic relationship between personal factors and the organizational and political contexts of care work. Whether moral distress actually leads to a reduced well-being of health care workers or a reduced quality of care in the sector depends to a large extent on how moral tensions are dealt with, also called moral resilience, and the protective conditions available. Research about moral distress and moral resilience within the field of health care has concentrated on staff nurses and physicians. Studies into palliative terminal care and/or about the role of coordinating staff are scarce. A study was conducted to gain insight into the moral challenges that coordinators in voluntary palliative terminal care encounter in their ambition to realize good care, how they deal with these challenges, and the individual and organizational characteristics that foster or hamper moral resilience. Interviews were conducted with 20 coordinators and were qualitatively analyzed. The results brought forward 3 moral challenges in working with volunteers and in collaborating with professional care, namely, striving for connection, negotiating autonomy, and struggling with open communication. However, coordinators seemed to face these challenges effectively. In conclusion, the relational narrative strategies used by coordinators to deal with these challenges, in combination with personal and organizational conditions, foster moral resilience.

Nurses’ experiences of the ethical values of home care nursing: A qualitative study

Objective

Considering the importance of out-of-hospital services, the emergence of home care nursing, and the need for an ethical framework in nursing practice, the present study aimed to explore the nurses’ experience of ethical values of home care nursing.

Methods

The data of the study was collected using face-to-face individual interviews. Through purposive sampling, 20 nurses who worked in the home care centers in four cities of Iran in 2020 were interviewed. They shared their experiences of the ethical values of home care nursing. Then, the interviews were analyzed based on the content analysis approach and using Graneheim and Lundman method.

Results

In the present study, 416 codes were extracted. Merging these codes based on the similarity, seven main themes, and 16 sub-themes were extracted. The themes included perception of the professional identity, respect for the client’s autonomy, respecting privacy, establishing human interaction, maintaining mutual safety, observance of justice, and cultural-religious competence. The sub-themes included responsibility, development of professional and inter-professional interactions, maintaining the professional status at home, providing the holistic artistic care, patient’s privacy, nurse’s privacy, and maintaining the confidentiality of information, respect for the client’s choice, honestly informing, empathetic interaction, adjusting the power positions, client's safety, nurse’s safety, establishing justice, respect for the religious beliefs at home and cultural sensitivity.

Conclusion

The participants stated that due to entering the patient’s privacy in the home care cases, the ethical values such as perception of the professional identity, privacy, family interactions’ management, mutual security, and cultural-religious competence became doubly important compared to the hospital caring.

Meaning of Respect for Older People in Family Relationships

Background: Older people have various physical and mental health needs and often receive help from their family members to perform their daily life activities. This research aimed to explore the meaning of respect for older people in family relationships. Methods: A qualitative study using a content analysis approach was conducted. Semi-structured interviews were performed with sixteen older people and four family members. Results: Three main categories were developed: “respect for personal interests”, “kind and sincere respect” and “respect for autonomy”. Understanding of the meaning of respect for older people was influenced by special expectations from family members in terms of meeting personal needs, consideration of preferences and interests and empowerment and support to help preserve older people’s independence and autonomy. Conclusions: Family members should be informed and educated with regard to their expected roles in family relationships, and should consider respect as an important factor affecting older people’s well-being.

Stress, strength, and respect: Viewing direct care staff experiences through a trauma-informed lens

Trauma-informed approaches may promote the well-being of CNAs and disrupt organizational practices that perpetuate inequities. There is a dearth of literature addressing evidence-based, trauma-informed training for direct care staff, yet CMS now requires trauma-informed care in nursing homes. Five focus groups exploring trauma and resilience-related concepts were conducted using an expressive-collaborative model with 18 CNAs at four nursing homes. A thematic analysis was conducted and themes were identified related to identity, relationships with residents, organizational values, and personal wellness. CNAs voiced frustration at limited time and support to implement well-being or stress management practices. Relationships with residents were sources of strength and, conversely, sources of emotional injury due to disrespect, disregard, and hostile behavior directed at CNAs. Central to health and well-being, CNAs called for change within facility cultures experienced as disrespectful, inequitable, and contrary to work-life balance. Trauma-informed training can be used to give particular attention to direct care staff. Administrators would benefit from learning about trauma and resilience among CNAs and precipitating organizational factors such as reasonable care ratios, equitable benefits, and peer support that impact CNA well-being, job satisfaction, and quality of care. The development and implementation of a trauma-informed training curriculum for CNAs are warranted.

Keeping calm on a busy day-an interpersonal skill home care patients desire in health workers: hermeneutical phenomenological method

Background

In Western countries, many health and social care provisions have been transferred to primary care, and most older patients wish to remain in their own homes for as long as possible. For older patients who live alone, health workers could be their only personal contacts. Hence, health workers’ personal skills affect their relationships with these patients. Accordingly, this study aimed to shed light on the interpersonal skills needed by health workers to establish good relationships with older home care patients and highlight the importance of interpersonal skills training in nursing education.

Methods

This study adopted a hermeneutical phenomenological approach. The qualitative method was used to elicit data on patients’ perspectives. Ten home care patients were interviewed individually in their own homes between December 2019 and January 2020.

Results

Despite individual variations, health workers’ interpersonal skills are of significance with regard to the social well-being of patients living at home. The findings revealed that patients want health workers to be mentally present, congruent in their communications, calm and relaxed during the available time spent with them, and capable of facilitating autonomy.

Conclusions

It is important to present patients’ perspectives to ensure that nursing education is geared towards patients’ best interests.

Trial registration number

The Norwegian Centre for Research Data (NSD): 953937.

Preserving client autonomy when guiding medicine taking in telehomecare: A conversation analytic case study

Background: Enhancing client autonomy requires close coordination of interactional practices between nurse and client, which can cause challenges when interaction takes place in video-mediated settings. While video-mediated services have become more common, it remains unclear how they shape client autonomy in telehomecare. Research aim: To analyse how video mediation shapes client autonomy when nurses guide medicine taking remotely through video-mediated home care. Research design: This is a conversation analytic case study using video recordings of telehomecare encounters. The theoretical approach draws on ethnomethodology and empirical ethics. Participants and research context: Four home-dwelling older adults and three nurses participated in the data collection; data extracts include one client and two nurses. The study was conducted in Finland. Ethical considerations: Special attention was given to protect the rights of home care clients. An ethical statement for the study was given by the Ethics Committee of the Tampere Region Findings: Video mediation complicates interacting remotely with care-relevant artefacts because of nurses’ limited visual access to the medicine and client’s need to simultaneously engage in vocal interaction and medicine taking. This can be overcome by dividing the guidance into manageable steps which invite the client to explicate their readiness to take the medicine and situating the video-mediation equipment and medicine close together. Different interactional practices and ways of situating video-mediation equipment and medicine have consequences for client autonomy. Discussion: Understanding client autonomy in digitalised settings demands empirical examination that recognises the importance of different human and non-human aspects of care that shape client autonomy. Conclusions: To harness the benefits of video-mediated home care, communication technologies’ reliance on home space and interactional practices should be recognised. Empirical ethics research is needed in order to make normative suggestions that fit a wide variety of care situation.

Are comprehensive and individually designed care and service plans for older people's home care a vision or a reality in Finland?

The global population is ageing and many older people want to continue to live in their own homes, supported by home-care services. The basis for comprehensive care is real-time care and service plans, but more knowledge is needed about these plans to ensure that older people benefit from individual and comprehensive home care. Our aim was to describe the contents of older home-care clients' care and service plans by using the Finnish Care Classification (FinCC), version 3.0, which includes the Finnish classification of nursing diagnoses (FiCND) and the Finnish classification of nursing interventions (FiCNI). The data were collected during spring 2018 from 71 anonymised care and service plans provided by 47 registered and practical nurses who worked for one government-funded home-care organisation in an urban region of Finland. We analysed the data using descriptive statistical methods. The documentation focused on daily activities, but was based on a narrow view of individual needs and comprehensive care planning. In addition, we found a statistically significant association between documented clients' needs (FiCND) and nursing interventions (FiCNI) in secretions, fluid balance, respiration and skin integrity. The client's age, gender, how long they had been receiving home care and the number of home visits they received each week were all associated with certain documented needs and interventions. Our findings provide new knowledge about inconsistent documentation related to clients' needs and nursing interventions. Collaboration between technical and home-care professionals is needed to develop and test specific content in the FinCC related to home care. The contents should also take into account the views of older people on how they want their care and services needs to be planned and delivered so that they can lead independent and fulfilling lives.

Primary healthcare nurses' involvement in patient and community participation in the context of chronic diseases: An integrative review

BACKGROUND

Primary healthcare nurses' potential to enable patient and community participation has been increasingly acknowledged. A conceptual understanding of their contributions within a broad range of participation processes is still lacking.

AIMS

The aims of this study were to develop a conceptual framework that provides information on the role of primary healthcare nurses in shaping participation processes with patients and communities in the context of chronic diseases and to identify conditions that enable or hinder the promotion of patient and community participation by nurses.

DESIGN

An integrative review was conducted.

DATA SOURCES

Twenty-three articles published from 2000 to 2019 were included in the analysis: 19 retrieved from PubMed and CHINAL and 4 added through other sources.

REVIEW METHODS

An inductive data analysis and quality appraisal of studies were conducted.

RESULTS

The analysis reveals four areas where nurses are involved in facilitating patient and community participation: (1) sharing understanding of health problems and needs, (2) developing resources and facilitating patient education for self-management, (3) raising patients' voices as an advocate in service development and (4) supporting individual and community networks. The conditions affecting nurses' engagement in fostering participation processes are as follows: (1) care priorities and overall workload, (2) nurses' attitudes towards participation and (3) users' acceptance of nurses as partners.

CONCLUSIONS

Future research can use the framework as a basis for empirical studies investigating nurses' involvement in pursuing patient and community participation. Interventions should focus less on indirect forms of participation, like patient education or advocacy, but should also focus on active forms of participation. Research is needed on nurses' involvement in community participation processes.

IMPACT

This framework can be used and adapted in future research on patient and community participation in primary healthcare. It describes areas of participation and the facilitators and barriers within the broad range of activities of primary healthcare nurses.

Ethical challenges in home-based care: A systematic literature review

Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted.

The Perceptions of People with Dementia and Key Stakeholders Regarding the Use and Impact of the Social Robot MARIO

People with dementia often experience loneliness and social isolation. This can result in increased cognitive decline which, in turn, has a negative impact on quality of life. This paper explores the use of the social robot, MARIO, with older people living with dementia as a way of addressing these issues. A descriptive qualitative study was conducted to explore the perceptions and experiences of the use and impact of MARIO. The research took place in the UK, Italy and Ireland. Semi-structured interviews were held in each location with people with dementia (n = 38), relatives/carers (n = 28), formal carers (n = 28) and managers (n = 13). The data was analyzed using qualitative content analysis. The findings revealed that despite challenges in relation to voice recognition and the practicalities of conducting research involving robots in real-life settings, most participants were positive about MARIO. Through the robot's user-led design and personalized applications, MARIO provided a point of interest, social activities, and cognitive engagement increased. However, some formal carers and managers voiced concern that robots might replace care staff.

Nursing Care Ethical Implications Regarding Chronic Patients at Hospital Discharge

Mortality rates among pluripathological patients are significantly higher in the hospital setting, with advanced age and dependence on certain vital functions the main clinical aspects. Other features involved in the care, such as the loss of autonomy and social problems, have important ethical implications. The aim of this article is to analyze the health problems and the functional and social situation of chronic patients after hospital admission in order to determine their care needs and the ethical implications these might have. For this, a cross-sectional descriptive study is being carried out with a sample of 111 chronic pluripathological patients admitted to the internal medicine service and discharged later. Overall, 96.6% of the patients in the sample were dependent, 91.7% had social problems or were at social risk and 36.9% had cognitive impairment. Among dependent patients, 59.4% had social problems (p = 0.029), 19.2% lived alone (p = 0.13), and in 73.3% of cases the housing was inadequate (p = 0.47). Among those with cognitive impairment, 79.5% of patients had social problems (p = 0.001), and 10.3% lived alone (p = 0.038). The results of the study confirm the presence of dependence and social problems at hospital discharge in a high proportion of chronic patients. Planning their care can lead to ethical conflicts related to the use of information technologies, which are destined to promote the patients' autonomy, and to the social problems associated with the illness.

Experiences of Older Spousal Caregivers for Caring a Person with a Memory Disorder

Memory disorders have become a major public, social, and health concern among the aging population, and many of those who are affected are cared for at home by their spouse. The aim of this qualitative study was to describe the individual experiences of 10 older caregivers who were looking after a spouse with a memory disorder in 2016. Data were collected from volunteers who were recruited from a memory clinic at a Finnish health center using the thematic interview method and processed using inductive content analysis. The participants were six female and four male caregivers who had been married for over 10 years. The results indicated that caring for a spouse with a memory disorder involved a number of factors. These included the impact of social networks and changes in their everyday life, collaboration with service providers, and the caregivers’ well-being. However, our study showed that caregivers felt that the formal multiprofessional services they received were fragmented, which means that they were less likely to provide a holistic approach to caregivers’ situations. Better multiprofessional cooperation is needed in the community, including services such as memory clinics, home care and practical services, day centers, and short-term respite in care homes.

Facilitators and barriers to autonomy: a systematic literature review for older adults with physical impairments, living in residential care facilities

Autonomy is important in every stage of life. However, little is known about how autonomy is enhanced for older adults living in residential care facilities (RCFs). This leads to the research question: which facilitators and barriers to autonomy of older adults with physical impairments due to ageing and chronic health conditions living in RCFs are known? The results will be organised according to the framework of person-centred practice, because this is related to autonomy enhancement. To answer the research question, a systematic literature search and review was performed in the electronic databases CINAHL, PsycINFO, PubMed, Social Services Abstracts and Sociological Abstracts. Inclusion and exclusion criteria were derived from the research question. Selected articles were analysed and assessed on quality using the Mixed Methods Appraisal Tool. Facilitators and barriers for autonomy were found and arranged in four themes: characteristics of residents, prerequisites of professional care-givers, care processes between resident and care-giver, and environment of care. The established facilitators and barriers are relational and dynamic. For a better understanding of the facilitators and barriers to autonomy for older adults with physical impairments living in RCFs, a description is based on the 35 included articles. Autonomy is a capacity to influence the environment and make decisions irrespective of having executional autonomy, to live the kind of life someone desires to live in the face of diminishing social, physical and/or cognitive resources and dependency, and it develops in relationships. The results provide an actual overview and lead to a better understanding of barriers and facilitators for the autonomy of older adults with physical impairments in RCFs. For both residents and care-givers, results offer possibilities to sustain and reinforce autonomy. Scientifically, the study creates new knowledge on factors that influence autonomy, which can be used to enhance autonomy.

Dealing with ethical and existential issues at end of life through co-creation

BACKGROUND

In research on co-creation in nursing, a caring manner can be used to create opportunities for the patient to reach vital goals and thereby increase the patient's quality of life in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. Nurses must be extra sensitive to patients' and their relatives' needs with regard to ethical and existential issues and situations in home care encounters, especially at the end of life.

AIM

The aim of this study was to explore nurses' experiences of dealing with ethical and existential issues through co-creation at the end of life in palliative home care.

RESEARCH DESIGN, PARTICIPANTS, AND RESEARCH CONTEXT

The material consisted of texts from interviews with 12 nurses in a home care context. A hermeneutical approach was used, and the method was inspired by a thematic analysis.

ETHICAL CONSIDERATIONS

Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. Ethical permission to conduct the study was given from organizations that participated in this study.

FINDINGS

A main theme and four subthemes emerged. The main theme was "Deep co-creative relationships are needed to manage ethical and existential issues at the end of life." A model was created to display the findings and relations between ethical issues and situations and the need for a deep trustful caring relationship to solve problems in palliative home care.

DISCUSSION

Together, the themes can be considered as a tool for learning and dealing with ethical and existential issues at the end of life in home care. The themes can also be seen as a part of nurses' ethical competence within this context.

CONCLUSION

The quality of life at the end of life can be improved through co-creation, despite difficult ethical and existential issues. Future research should focus on co-creation from the patients' perspective.