Exploring the meaning of a good life for older widows with extensive need of care: a qualitative in-home interview study

INTRODUCTION

Studies of older women's life transitions is rare but gains relevance as the aging population, with older women as the majority, expands.

PURPOSE

To explore the meaning of a good life for older widows with extensive home care needs.

MATERIALS AND METHODS

Semi-structured interviews were carried out with eleven women, aged 80 and over (82-95 years, mean 90) residing at home with extensive care needs (≥4 daily sessions, averaging 2.5-6 hours, mean 3). Data were analysed by reflexive thematic analysis.

RESULTS

The theme "This Day in My Home, the frame of my life" reflects the women's experience of a good life. A good day imbued them with hope, trust and security, carrying them forward with the assurance that night would usher in a new day. However, there were moments when life was merely about navigating daily challenges. During such days, the women felt trapped in time, unsafe and lonely.

CONCLUSION

A day at home may seem static, yet it mirrors life's dynamism, evolving with shifting circumstances. Older widows navigate challenges while maintaining their sense of self, independence, and connection to home. These findings have implications for aged care, recognizing the multifaceted aspects of life and the centrality of home.

Self-rated health in old age, related factors and survival: A 20-Year longitudinal study within the Silver-MONICA cohort

INTRODUCTION

Self-rated health (SRH) offers insights into the evolving health demographics of an ageing population.

AIM

To assess change in SRH from old age to very old age and their associations with health and well-being factors, and to investigate the association between SRH and survival.

METHODS

All participants in the MONICA 1999 re-examination born before 1940 (n = 1595) were included in the Silver-MONICA baseline cohort. The Silver-MONICA follow-up started in 2016 included participants in the Silver-MONICA baseline cohort aged 80 years or older. Data on SRH was available for 1561 participants at baseline with 446 of them also participating in the follow-up. The follow-up examination included a wide variety of measurements and tests.

FINDINGS

Most participants rated their health as "Quite good" (54.5 %) at baseline. Over the study period, 42.6 % had stable SRH, 40.6 % had declined, and 16.8 % had improved. Changes in SRH were at follow-up significantly associated with age, pain, nutrition, cognition, walking aid use, self-paced gait speed, lower extremity strength, independence in activities of daily living, weekly physical exercise, outdoor activity, participation in organized activities, visiting others, morale, and depressive symptoms. SRH at baseline was significantly associated with survival (p < 0.05).

CONCLUSION

This study demonstrates associations between changes in SRH and a multitude of health- and wellbeing-related factors, as well as a relation between survival and SRH, accentuating their relevance within the ageing population.

Experiences with continuous quality improvement work based on the Occupational Therapy Intervention Process Model

BACKGROUND

Sustainability is an important issue in implementation processes in health care, and more knowledge is needed to facilitate improvement work in occupational therapy practice.

AIM

The aim of this study was to explore how occupational therapists experienced continuous quality improvement work based on the Occupational Therapy Intervention Process Model after 17 years.

METHOD

Two focus group interviews were conducted with a total of 12 occupational therapists. The data were analysed using qualitative content analysis.

RESULTS

The analysis resulted in three themes with related subthemes describing the occupational therapists' experiences of their model-based long-term improvement work. The themes were labelled as follows: 'sharing a safe and well-known professional reasoning', 'reaching normality and empowerment' and 'questioning and reshaping the too safe and too well-known normality'. The model functioned as a sustainable framework both for ordinary clinical practice and for continuous improvement work.

CONCLUSION

By using the model, the occupational therapists had established a safe and well-known professional reasoning in which continual quality improvement work had become sustainable.

Descriptions of long-term impact from inter-professional ethics communication in groups

BACKGROUND

On a daily basis, healthcare professionals deal with various ethical issues and it can be difficult to determine how to act best. Clinical ethics support (CES) has been developed to provide support for healthcare professionals dealing with complex ethical issues. A long-term perspective of participating in inter-professional dialogue and reflective-based CES sessions is seemingly sparse in the literature.

RESEARCH AIM

The aim was to describe experiences of impact of Inter-professional Ethics Communication in groups (IEC) based on Habermas' theory of communicative actions, after 6 months from the perspective of an inter-professional team.

RESEARCH DESIGN

A qualitative inductive approach was chosen, and individual interviews (n = 13) were conducted. Interview data were analysed using qualitative content analysis.

PARTICIPANTS

The participants, 10 females and two males, represented assistant nurses, registered nurses, physicians, occupational therapists, physiotherapists, welfare officers and psychologists. Each had attended at least four IEC sessions.

ETHICAL CONSIDERATIONS

The study was approved by the Regional Ethical Review Board in Umeå, Sweden, and it has been undertaken in accordance with the Helsinki Declaration.

FINDINGS

Overall, the descriptions expressed a perceived achievement of a deepened and integrated ethical awareness that increased the participants' awareness of ethically difficult situations as well as their own ethical thinking, actions and approaches in daily work. Perspectives were shared and the team become more welded. They carried the memories of the reflections within them, which was perceived as supportive when encountered new ethically situations.

DISCUSSION

Putting words to unarticulated thoughts may stimulate repeated reflections, leading to new insights and alternative thoughts.

CONCLUSION

The outcome of IEC sessions 6 months following the last session can be described as an incorporated knowledge that enables actions in ethically difficult situations based on an ethical awareness both at a 'We-level' and an 'I-level'.

“It’s all about time and timing”: nursing staffs’ experiences with an agile development process, from its initial requirements to the deployment of its outcome of ICT solutions to support discharge planning

Background

Agile projects are statistically more likely to succeed then waterfall projects. The overall aim of this study was to explore the nursing staffs’ experiences with an agile development process, from its initial requirements to the deployment of its outcome of ICT solutions aimed at supporting discharge planning.

Methods

An explorative design with quantitative and qualitative methods was used. Qualitative data was collected through seven focus group interviews. Quantitative data was collected via an ICT-system, and with an evaluation form submitted by fourteen registered nurses and nine district nurses.

Results

Qualitative result of the experiences with the agile development process and its outcome resulted in one theme, four categories, and ten subcategories. The theme was found to be about time and timing, namely the amount of time for the different activities and the timing of activities within and between organisations. The agile development process increased the participants’ readiness for change by offering time to learn, practice, engage and reflect, and then adopt the ICT as a support to daily practice. Quantitative results showed a variated adoption of the ICT.

Conclusion

There is a need for time to prepare, understand and adopt new tools, services and procedures and a need for additional time to prepare, understand and adopt the new among individuals, collectives, organizations, and sometimes even between different collectives or organizations. The agile development process offered the end-users involvement through the development process, which gave them time to change it both individually and collectively. However, there is a need for close collaboration between the development project team and management to reach an organizational change that is timely for both the individual and the collective change. When time or timing fails in the development or implementation process, there is a huge risk of non-adoption of new tools, services, or procedures or among the end-users.

Associations between everyday physical activity and morale in older adults

Studies that objectively investigate patterns of everyday physical activity in relation to well-being and that use measures specific to older adults are scarce. This study aimed to explore objectively measured everyday physical activity and sedentary behavior in relation to a morale measure specifically constructed for older adults. A total of 77 persons (42 women, 35 men) aged 80 years or older (84.3 ± 3.8) wore an accelerometer device for at least 5 days. Morale was measured with the Philadelphia Geriatric Center Morale Scale (PGCMS). PGCMS scores were significantly positively associated with number of steps, time spent stepping, and time spent stepping at >75 steps per minute. Sedentary behavior did not associate with PGCMS. Promoting PA in the form of walking at any intensity-or even spending time in an upright position-and in any quantity may be important for morale, or vice versa, or the influence may be bidirectional.

Experiences of home as an aspect of well-being in people over 80 years: A mixed method study

AIMS

To (1) describe experiences of home from a well-being perspective, (2) describe participant characteristics and well-being measures in relation to housing type (3) and how the aforementioned aspects may affect well-being in very old persons.

DESIGN

Cross-sectional, convergent parallel-results mixed method design with semi-structured interviews analysed by qualitative content analysis, in relation to descriptive statistics and specific well-being outcome measures related to home.

METHODS

A total of 50 persons 80 years or older living in ordinary housing were interviewed (July 2017 to November 2018) about home in relation to well-being, along with collection of participant characteristics and well-being measures related to home.

RESULTS

Participants described how home had become increasingly important as it provided autonomy and acted as a social and occupational hub. However, autonomy was not unconditional, and home could also be perceived as a place of inactive solitude. Results were interpreted as relating to being in the margins of home and had a major impact on well-being. Housing type seemed of importance with higher measures of well-being for participants in single-living housing compared with those living in apartment.

CONCLUSION

Home is increasingly central to well-being in old age; however, very old persons also have to relate to being physically and mentally in the margins of being able to remain in the home. These aspects of home potentially have a major impact on well-being.

IMPACT

As very old persons living in ordinary housing will constitute a larger segment of society in coming years, aspects of home can potentially have a considerable impact on well-being for this age-group. This study describes aspects of home that contribute to, or has adverse impact on well-being. These aspects need thorough consideration in policy-making and planning of health care that can affect experiences of home.

The 'one to five' method - A tool for ethical communication in groups among healthcare professionals

Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The 'one to five method' supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.

Accepting the inevitable: A mixed method approach with assessment and perceptions of well-being in very old persons within the northern Sweden Silver-MONICA study

BACKGROUND

As the group of very old persons will form an increasing part of society, the study of how well-being is described and affected by specific factors will be of importance to meet the future needs of these persons. The aim of the study was to increase knowledge of well-being in very old persons by combining assessments and perceptions using the Philadelphia Geriatric Morale Scale (PGCMS).

METHOD

In a mixed method, convergent parallel design, 52 persons 80 years or older were assessed and interviewed using the PGCMS to combine assessment of morale and descriptions of perceptions of well-being using a mixed method approach.

RESULTS

Quantitative and qualitative results converged in four areas: not feeling lonely and being included, rating and perceiving health as good, high physical function/ability and being physically active, living in own house and feeling at home. Areas perceived as important to well-being captured only in qualitative analysis were having freedom and engagement. An example of insights not achievable from the quantitative or qualitative analysis alone was that individuals with high morale expressed anxiety about losing their health due to potential ageing-related threats and that individuals with low morale struggled with acceptance. Acceptance was the key strategy for handling adverse consequences of ageing in all described areas.

CONCLUSION

When using standardized assessment scales in clinical practice, it could be useful to combine quantitative and qualitative data. Acceptance was key for well-being; however, acceptance could be resigned or reorienting in nature.

Organizing for sustainable inter-organizational collaboration in health care processes

Integrating health care services has proven to be important from both the patient and organizational perspectives. This study explores what defines a perceived well-functioning collaboration in the inter-organizational process of providing assistive devices in Sweden. Two focus groups comprising participants with profound knowledge of collaboration were performed, and data were analyzed in five steps, resulting in a data structure. Results yield the identification of three interacting processes: coordinating efforts to patient needs, ensuring evidence-based practice, and planning for efficient use of resources. These processes affected one another, and, therefore, would likely not have been effectively managed separately. The study contributes to theories of process management and organization by specifically focusing on how to analyze and improve sustainable collaboration in health care processes at both the management and professional levels. Theoretical frameworks that show different ways of organizing collaboration, as well as the concepts of action nets and boundary objects, can support both analysis and planning of collaboration. The intention would be to develop integration in inter-organizational health care processes, resulting in more person-centered care.

Meeting in a ‘free-zone’: Clinical ethical support in integrated heart-failure and palliative care

Background:

Integrating heart-failure and palliative care combines expertise from two cultures, life-saving cardiology and palliative care, and involves ethically difficult situations that have to be considered from various perspectives. We found no studies describing experiences of clinical ethical support (CES) in integrated cardiology and palliative care teams.

Objective:

Our aim is to describe experiences of CES among professionals after a period of three years working in a multidisciplinary team in integrated heart-failure and palliative homecare.

Method:

The study design was descriptive qualitative, comprising interviews with seven professionals from one integrated heart-failure and palliative care team who received CES over a three-year period. The interview data were subjected to qualitative content analysis.

Results:

The CES was found to offer possibilities for meeting in an ethical ‘free-zone’ where the participants could relate to each other beyond their various professional roles and specialties. The trust within the team seemed to increase and the participants were confident enough to express their points of view. Together they developed an integrated understanding, and acquired more knowledge and a comprehensive view of the ethically difficult situation of concern. The CES sessions were considered a means of becoming better prepared to deal with ethical care issues and developing action strategies to apply in practice, from shared standpoints.

Conclusion:

Participating in CES was experienced as meeting in an ethical ‘free-zone’ and seemed to be a means of facilitating integration of palliative and heart-failure care.

Communicative and organizational aspects of clinical ethics support

Studies show that healthcare professionals need inter-professional clinical ethics support (CES) in order to communicate and reflect on ethically difficult care situations that they experience in their clinical practice. Internationally, various CES interventions have been performed, but the communication processes and organisation of these interventions are rarely described in detail. The aim of this study was to explore communicative and organisational conditions of a CES intervention with the intention of promoting inter-professional communication about ethically difficult care situations. Eight audio- and video-recorded inter-professional CES sessions, inspired by Habermas' theory of communicative actions, were conducted. The observations were transcribed, sorted, and analysed using concept- and data-driven content analysis methods. The findings show three approaches to promoting communicative agreement, which include the CES facilitators' and participants' approaches to promoting a permissive communication, extended views, and mutual understanding. The CES sessions had organizational aspects for facilitating communicative agreement with both a given structure and openness for variation. The dynamic structure of the organization, promoted both safety and stability as well as a creativity and responsiveness, which in turn opened up for a free and dynamic inter-professional dialogue concerning ethically difficult care situations. The findings constitute a step towards a theory-based CES method inspired by Habermas' theory of communicative action. Further research is needed in order to fully develop the method and obtain increased knowledge about how to promote an inter-professional dialogue about ethically difficulties.

Organisational and environmental characteristics of residential aged care units providing highly person-centred care: a cross sectional study

BACKGROUND

Few studies have empirically investigated factors that define residential aged care units that are perceived as being highly person-centred. The purpose of this study was to explore factors characterising residential aged care units perceived as being highly person-centred, with a focus on organisational and environmental variables, as well as residents' and staff' characteristics.

METHODS

A cross-sectional design was used. Residents (n = 1460) and staff (n = 1213) data from 151 residential care units were collected, as well as data relating to characteristics of the organisation and environment, and data measuring degree of person-centred care. Participating staff provided self-reported data and conducted proxy ratings on residents. Descriptive and comparative statistics, independent samples t-test, Chi² test, Eta Squared and Phi coefficient were used to analyse data.

RESULTS

Highly person-centred residential aged care units were characterized by having a shared philosophy of care, a satisfactory leadership, interdisciplinary collaboration and social support from colleagues and leaders, a dementia-friendly physical environment, staff having time to spend with residents, and a smaller unit size. Residential aged care units with higher levels of person-centred care had a higher proportion of staff with continuing education in dementia care, and a higher proportion of staff receiving regular supervision, compared to units with lower levels of person-centred care.

CONCLUSIONS

It is important to target organisational and environmental factors, such as a shared philosophy of care, staff use of time, the physical environment, interdisciplinary support, and support from leaders and colleagues, to improve person-centred care in residential care units. Managers and leaders seeking to facilitate person-centred care in daily practice need to consider their own role in supporting, encouraging, and supervising staff.

Aspects of Self and Identity in Narrations About Recent Events: Communication with Individuals with Alzheimer's Disease Enabled by a Digital Photograph Diary

The ability to narrate autobiographical memories is important for maintaining the identity of individuals with Alzheimer's disease (AD). The current study explored how the sense of self is manifested in narrations about recent events, enabled via a digital photograph diary. Use of a digital photograph diary was tested with seven individuals with AD and their household members. Narrative analysis was used to analyze audiorecordings of the pairs' communication about recent events shown in the photographs. The results show how individuals with AD understand events illustrated in recent photographs in relation to their sense of self and associated skills and abilities that are facets of their selfhood. This type of digital photograph diary has the potential to support individuals with AD to maintain their sense of self and participation in everyday life, and strengthen their relationships with household members; it could be an important tool in person-centered care. [Journal of Gerontological Nursing, 43(6), 25-31.].

Managing Ethical Difficulties in Healthcare: Communicating in Inter-professional Clinical Ethics Support Sessions

Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support (CES) inspired by Habermas' theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved.

Patients with acute stroke are less likely to be admitted directly to a stroke unit when hospital beds are scarce: A Swedish multicenter register study

Introduction

It is well established that managing patients with acute stroke in dedicated stroke units is associated with improved functioning and survival. The objectives of this study are to investigate whether patients with acute stroke are less likely to be directly admitted to a stroke unit from the Emergency Department when hospital beds are scarce and to measure variation across hospitals in terms of this outcome.

Patients and methods

This register study comprised data on patients with acute stroke admitted to 14 out of 72 Swedish hospitals in 2011-2014. Data from the Swedish stroke register were linked to administrative daily data on hospital bed occupancy (measured at 6 a.m.). Logistic regression analysis was used to analyse the association between bed occupancy and direct stroke unit admission.

Results

A total of 13,955 hospital admissions were included; 79.6% were directly admitted to a stroke unit from the Emergency Department. Each percentage increase in hospital bed occupancy was associated with a 1.5% decrease in odds of direct admission to a stroke unit (odds ratio = 0.985, 95% confidence interval = 0.978-0.992). The best-performing hospital exhibited an odds ratio of 3.8 (95% confidence interval = 2.6-5.5) for direct admission to a stroke unit versus the reference hospital.

Discussion and conclusion

We found an association between hospital crowding and reduced quality of care in acute stroke, portrayed by a lower likelihood of patients being directly admitted to a stroke unit from the Emergency Department. The magnitude of the effect varied considerably across hospitals.

Video-phone communication with cognitively impaired elderly patients

We investigated the potential role of remote interactions via video-phone in the care of the elderly. Family members and nursing staff were interviewed about their experiences of communicating with elderly people via video-phone. Seven family members and seven nursing staff participated in the studies. The interviews were analysed using qualitative content analysis. The results showed that it was possible for elderly people with cognitive impairment to engage in remote communication when certain conditions were met. There were also indications that the video-phone interaction sometimes increased the attention and focus of the elderly subjects.

Experience of at-homeness and homesickness in patients with Alzheimer's disease

In order to gain deeper understanding of the patient's everyday life participant and non-participant observations were performed at a group-dwelling for Alzheimer patients, during one year and eight months. The patients' talking and acting in various situations were noted, and the contexts were described. The phenomena, “longing for home,” “on their way home “ and “being at home “ were identified and regarded as expressions of the experience of homesickness and at homeness in the patients.

Process evaluation of discharge planning implementation in healthcare using normalization process theory

BACKGROUND

Discharge planning is a care process that aims to secure the transfer of care for the patient at transition from home to the hospital and back home. Information exchange and collaboration between care providers are essential, but deficits are common. A wide range of initiatives to improve the discharge planning process have been developed and implemented for the past three decades. However, there are still high rates of reported medical errors and adverse events related to failures in the discharge planning. Using theoretical frameworks such as Normalization Process Theory (NPT) can support evaluations of complex interventions and processes in healthcare. The aim of this study was to explore the embedding and integration of the DPP from the perspective of registered nurses, district nurses and homecare organizers.

METHODS

The study design was explorative, using the NPT as a framework to explore the embedding and integration of the DPP. Data consisted of written documentation from; workshops with staff, registered adverse events and system failures, web based survey and individual interviews with staff.

RESULTS

Using the NPT as a framework to explore the embedding and integration of discharge planning after 10 years in use showed that the staff had reached a consensus of opinion of what the process was (coherence) and how they evaluated the process (reflexive monitoring). However, they had not reached a consensus of opinion of who performed the process (cognitive participation) and how it was performed (collective action). This could be interpreted as the process had not become normalized in daily practice.

CONCLUSION

The result shows necessity to observe the implementation of old practices to better understand the needs of new ones before developing and implementing new practices or supportive tools within healthcare to reach the aim of development and to accomplish sustainable implementation. The NPT offers a generalizable framework for analysis, which can explain and shape the implementation process of old practices, before further development of new practices or supportive tools.

Customer orientation in a Swedish county council

Purpose

– The use of the customer concept and ways of interacting with customers in support functions are relatively new areas of interest for public organizations. The purpose of this study is to describe the development toward a stronger customer orientation in a support function in a Swedish county council from a management team perspective.

Design/methodology/approach

– A revision of plans and annual reports and individual interviews with the members of a management team was done. The interviews were examined using qualitative content analysis.

Findings

– The results are presented in one overarching theme, the double-edged customer concept, and three themes, meeting the customer’s needs, being the customer’s specialist and developing in collaboration with the customer. The development of a customer orientation is illustrated as a spiral involving the concepts of understanding, wanting and acting.

Originality/value

– The paper contributes to a new understanding of how customer orientation develops in the context of public organizations’ support functions.

Experiences and Views of the Discharge Planning Process Among Swedish District Nurses and Home Care Organizers

Discharge planning is an important care process, but deficits in planning are common. The aim of this study was to explore district nurses’ (DNs) and home care organizers’ (HCOs) experiences and views of the workflow during the discharge planning process (DPP). Demands, workload, time, collaboration, and engagement, together with knowledge and professional confidence, are factors that influence workflow and outcome of the DPP for DNs and HCOs. Strengths and obstacles at the organization, group, and individual levels affect the workflow during the discharge planning. Knowledge of these strengths and obstacles should help care providers in their practice as well as help management and politicians become more aware of prerequisites needed to achieve a safe and efficient workflow for securing the patient’s discharge.

To what extent is the work environment of staff related to person-centred care? A cross-sectional study of residential aged care

AIMS AND OBJECTIVES

To explore the relationship between staff characteristics, perceived work environment and person-centred care in residential aged care units.

BACKGROUND

Person-centred care is often described as the model of choice in residential aged care and in the care of persons with dementia. Few empirical studies have reported on the relationship between how staff experience different aspects of their work and person-centred care.

DESIGN

The study had a cross-sectional quantitative design.

METHODS

Staff in 151 residential aged care units in Sweden (n = 1169) completed surveys which included questions about staff characteristics, valid and reliable measures of person-centred care, satisfaction with work and care, job strain, stress of conscience and psychosocial unit climate. Statistical analyses of correlations, group differences and multiple linear regression analysis estimated with generalised estimating equation were conducted.

RESULTS

Higher levels of staff satisfaction, lower levels of job strain, lower levels of stress of conscience, higher levels of a supportive psychosocial unit climate and a higher proportion of staff with continuing education in dementia care were associated with higher levels of person-centred care. Job strain and a supportive psychosocial climate, explained most of the variation in person-centred care.

CONCLUSIONS

This study shows that the work environment as perceived by staff is associated with the extent to which staff perceive the care as being person-centred in residential aged care. These empirical findings support the theoretical postulation that the work environment is an important aspect of person-centred care.

RELEVANCE TO CLINICAL PRACTICE

Promoting a positive and supportive psychosocial climate and a work environment where staff experience balance between demands and control in their work, to enable person-centred care practice, seems to be important implications for managers and leaders in residential aged care.

A process for developing sustainable evidence-based occupational therapy practice

OBJECTIVE

The purpose of this qualitative descriptive study was to describe how long-term improvement work based on the Occupational Therapy Intervention Process Model (OTIPM) evolved in an occupational therapy unit.

METHOD

Data included written documents related to the improvement work (435 pages in total) from 2001 to 2013 that were analysed using pattern matching.

RESULTS

The findings from the analysis of the documents formed three main patterns describing reorientation towards the OTIPM, establishment of the implementation of the OTIPM, and ensuring the sustainability of the implementation. Each pattern contained a number of phases of the improvement work emanating from different reasons and resulting in different long-term achievements. The transformation between the phases was smooth, and several of the phases became starting points for improvement work that continued throughout the years.

CONCLUSION

The findings showed how an occupational therapy model of practice, such as the OTIPM, can guide an improvement process and keep it going over a long period of time, thereby supporting sustainable improvements in practice.

Solving the staff's problem or meeting the patients' needs: staff members' reasoning about choice of action in challenging situations in psychiatric inpatient care

Coercion in challenging situations is often seen as a necessary component of psychiatric care. This study aims to describe staff members' reasoning about their choice of action in challenging situations in inpatient psychiatric care. Focus group interviews with 26 staff members were analyzed using qualitative content analysis. The results provide an overview of the integrated structure of participants' reasoning and suggest that staff members' reasoning about choice of action can be described as a matter of either solving the staff's problems or meeting the patients' needs. These results can be of use in further research, educational interventions, and staff development activities.

Conceptual development of "at-homeness" despite illness and disease: a review

Only one empirical study, the one by Zingmark, Norberg and Sandman published in 1995, explicitly focuses on at-homeness, the feeling of being metaphorically at-home, as a particular aspect of wellness. However, other studies reveal aspects of at-homeness, but if or how such aspects of at-homeness are related to each other is unclear. For this reason, the aim was to review Scandinavian nursing research related to at-homeness in the context of wellness-illness in severe and long-term conditions in order to take a step towards conceptual clarification of "at-homeness." The review included interpretive studies related to severe and long-term illness conducted in Sweden: 10 original articles and 5 doctoral theses. "At-homeness" was found to be a contextually related meaning of wellness despite illness and disease embedded in the continuum of being metaphorically at-home and metaphorically homeless. This was characterized by three interrelated aspects and four processes: being safe through expanding-limiting experiences of illness and time, being connected through reunifying-detaching ways of relating, and being centred through recognition-non-recognition of oneself in the experience and others giving-withdrawing a place for oneself. This conceptualization is to be regarded as a step in conceptual clarification. Further empirical investigation and theoretical development of "at-homeness" are needed. The conceptualization will be a step of plausible significance for the evaluation of interventions aimed at enhancing wellness for people with severe long-term illness, such as the frail elderly, and people with chronic illness or palliative care needs.

Stories about life narrated by people with Alzheimer's disease

AIM

To explore how people with Alzheimer's disease present their life story.

BACKGROUND

Life story work is a key concept in a person-centred care. An important aspect in understanding the subjective experience and supporting the identity of people with dementia is to listen to their life stories.

DESIGN

A narrative design with interviews was used.

METHOD

Nine participants with Alzheimer's disease were encouraged to tell about their lives from childhood, adult life, to present life and about their thoughts on the future. The interviews were conducted between September 2010-March 2011 in the participants' homes, with their spouses present and were analysed with a method for analysis of narratives.

FINDINGS

Contentment, Connectedness, Self-reliance and Personal growth were identified as core dimensions in the participants' life stories and shown like threads throughout life, from childhood, adult life to present life. All participants expressed an overall contentment with life, and connectedness was related to their relation with significant persons and to be included in the local community. Self-reliance was expressed as a strong confidence in the own ability and an overall curiosity throughout life as a sustained quest for personal growth.

CONCLUSIONS

It is important for healthcare professionals, who work with people with dementia, to understand that people with Alzheimer's disease can maintain an overall trusting and hopeful approach to life. It is also important to use life story work to enhance feelings of being connected to the world and thereby support their identity and sense of self.

The ambiguity of standing in standing devices: a qualitative interview study concerning children and parents experiences of the use of standing devices

AIM

The aim of this study was to describe children's and parents' experiences of the significance of standing in a standing device.

METHODS

Individual interviews were performed with six children/teenagers (aged 7-19 years) and 14 parents. The interviews were transcribed and analyzed using a qualitative content analysis.

FINDINGS

The analysis resulted in the major theme, the duality of uprightness and the related themes: (1) the instrumental dimension of standing; (2) the social dimension of standing; and (3) the ambivalent dimension of standing. Each of the themes comprised several subthemes.

CONCLUSIONS

There is an inherent duality related to the use of a standing device. Standing in a standing device was seen as a treatment of body structures and functions, as well as a possible source of pain. Standing was considered to influence freedom in activities and participation both positively and negatively. The parents experienced that standing influenced other peoples' views of their child, while the children experienced standing as a way to extend the body and as something that gave them benefits in some activities. Physiotherapists working with children should take into account both the social and physical dimensions of using a standing device and consider both the child's and the parents' views.

Knowledge of the patient as decision-making power: staff members' perceptions of interprofessional collaboration in challenging situations in psychiatric inpatient care

Challenging situations in psychiatric inpatient settings call for interprofessional collaboration, but the roles and responsibilities held by members of different professions is unclear. The aim of this study was to describe staff members' perceptions of interprofessional collaboration in the context of challenging situations in psychiatric inpatient care. Prior to the study taking place, ethical approval was granted. Focus group interviews were conducted with 26 physicians, ward managers, psychiatric nurses, and nursing assistants. These interviews were then transcribed and analysed using qualitative content analysis. Results described participants' perceptions of shared responsibilities, profession-specific responsibilities and professional approaches. In this, recognising knowledge of the patient as decision-making power was understood to be a recurring theme. This is a delimited qualitative study that reflects the specific working conditions of the participants at the time the study was conducted. The findings suggest that nursing assistants are the most influential professionals due to their closeness to and first-hand knowledge of patients. The results also point to the possibility of other professionals gaining influence by getting closer to patients and utilising their professional knowledge, thus contributing to a more person-centred care.

Supporting conversations between individuals with dementia and their family members

Remembrance of recent events is a major problem for individuals with dementia. Consequently, this article explores the process of acceptance and integration of a digital photograph diary (DPD) as a tool for remembrance of and conversations about daily life events. A design for multiple case studies was used. Seven couples, in which one individual in the couple had Alzheimer's disease, tested the DPD for 6 months. Data were collected in three sequences with interviews, observations, and screening instruments. In the analysis, all data were integrated to find common patterns of content. Some couples became regular users, while others used the DPD more sporadically. Factors contributing to regular use were how the DPD matched expectations, actual use, support, experienced usefulness, and reactions from family and friends. For those couples who became regular users, the DPD facilitated their conversation about recent daily activities.

Risk factors among people surviving out-of-hospital cardiac arrest and their thoughts about what lifestyle means to them: a mixed methods study

BACKGROUND

The known risk factors for coronary heart disease among people prior suffering an out-of-hospital cardiac arrest with validated myocardial infarction aetiology and their thoughts about what lifestyle means to them after surviving have rarely been described. Therefore the aim of the study was to describe risk factors and lifestyle among survivors.

METHODS

An explanatory mixed methods design was used. All people registered in the Northern Sweden MONICA myocardial registry between the year 1989 to 2007 who survived out-of-hospital cardiac arrest with validated myocardial infarction aetiology and were alive at the 28th day after the onset of symptoms (n = 71) were included in the quantitative analysis. Thirteen of them participated in interviews conducted in 2011 and analysed via a qualitative manifest content analysis.

RESULTS

About 60% of the people had no history of ischemic heart disease before the out-of-hospital cardiac arrest, but 20% had three cardiovascular risk factors (i.e., hypertension, diabetes mellitus, total cholesterol of more or equal 5 mmol/l or taking lipid lowering medication, and current smoker). Three categories (i.e., significance of lifestyle, modifying the lifestyle to the new life situation and a changed view on life) and seven sub-categories emerged from the qualitative analysis.

CONCLUSIONS

For many people out-of-hospital cardiac arrest was the first symptom of coronary heart disease. Interview participants were well informed about their cardiovascular risk factors and the benefits of risk factor treatment. In spite of that, some chose to ignore this knowledge to some extent and preferred to live a "good life", where risk factor treatment played a minor part. The importance of the support of family members in terms of feeling happy and having fun was highlighted by the interview participants and expressed as being the meaning of lifestyle. Perhaps the person with illness together with health care workers should focus more on the meaningful and joyful things in life and try to adopt healthy behaviours linked to these things.

The challenge of coming to terms with the use of a new digital assistive device: a case study of two persons with mild dementia

There is an increased interest in supporting persons with dementia with technical services in daily life. The aim of this case study was to explore the complex issues involved in the process from a user driven development to the acceptance and usage of a new digital assistive device for persons with mild dementia. Even though it was developed in a user driven process and personalized to meet their individual needs they rarely used it. To deepening the understanding of this disparity between actual usage and perceived usefulness, the participants were studied whilst performing daily life activities through participant observations and interviews. Their partners were interviewed two years after the first observations to clarify the change in needs over time. The results show that the participant needs encompassed occupation, safety, social interaction, and memory support together with the receipt of general support. The overriding requirement for both participants was a need to maintain their self-image. When the digital assistive device did not correspond with the participants' expectations or view of themselves, their interest in using it faded, since the digital assistive device failed to support their self-image. The acceptance of a digital assistive device by a person with dementia is a process that begins with identifying and personalizing the functions of the device according to individual needs, and then supporting the usage and the gradual integration of the device into daily life. During this process, the person's self-image must be taken into consideration and supported.

Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. An analysis of 8630 patients in the northern Sweden MONICA study

BACKGROUND

There is conflicting and only scant evidence on the effect of gender on long-term survival after a myocardial infarction (MI). Our aim was to analyse sex-specific survival of patients for up to 23 years after a first MI in northern Sweden and to describe time trends.

METHODS

The Northern Sweden MONICA Myocardial Infarction Registry was linked to The Swedish National Cause of Death Registry for a total of 8630 patients, 25 to 64 years of age, 6762 men and 1868 women, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008.

RESULTS

Median follow-up was 7.1 years, maximum 23 years and the study included 70 072 patient-years. During the follow-up 45.3% of the men and 43.7% of the women had died. Median survival for men was 187 months (95% confidence interval (CI) 179-194) and for women 200 months (95% CI 186-214). The hazard ratio (HR) for all cause mortality after adjustment for age group was 1.092 (1.010-1.18, P = 0.025) for females compared to males, i.e. 9 percent higher survival in women. After excluding subjects who died before reaching hospital HR declined to 1.017 (95%CI 0.93-1.11, P = 0.7). For any duration of follow-up a higher proportion of women were alive, irrespective of age group. The 5-year survivals were 75.3% and 77.5%, in younger (<57 years) men and women and were 65.5% and 66.3% in older (57-64 years) men and women, respectively. For each of four successive cohorts survival improved. Survival time was longer for women than for men in all age groups.

CONCLUSIONS

Age-adjusted survival was higher among women than men after a first MI and has improved markedly and equally in both men and women over a 23-year period. This difference was due to lower risk for women to die before reaching hospital.

Living with a person with Alzheimer's disease: Experiences related to everyday occupations

The aim of this study was to illuminate experiences of daily occupations among spouses living with a person with Alzheimer's disease (AD). The study contains phenomenological-hermeneutic interpretation of interviews with eight spouses. The analysis revealed the participants as being in the process of a changing occupational situation. They come to live an occupational life intertwined with their partners' needs. An ongoing process of occupational adjustment is taking place as a response to the changing situation. The spouses were occupied with consequences of their partner's disease. They were striving for occupational meaning and at the same time living with threats to meaningful occupations. It can be concluded that living with a partner with AD is a complex dealing with occupational meaning. This complexity should be considered in interventions.

The duality in using information and communication technology in elder care

AIM

The aim of this paper is to report a study illuminating values and perceptions held by professional carers of older people about the use of information and communication technology applications.

BACKGROUND

Various information and communication technology applications have successfully been developed to help solve a variety of problems in elder care. Beside different technical barriers and the assumed negative attitudes among older people, staff values and attitudes have been found to be an important cause of resistance to change and slowness in introduction of information and communication technology in health care of older people.

METHODS

An interview study was conducted in 2004 with 10 healthcare personnel with 3-26 years experience of working in home care and nursing homes in Northern Sweden. Qualitative content analysis was used to identify recurring themes in the data.

RESULTS

The interpretation of values and perceptions among carers revealed a duality where the carers perceived information and communication technology as a promoter of both inhumane and humane care, a duality that seemed to make them defensive and resistant to change. Within the overall duality, other dualities were embedded that described both perceptions about the care of older people and about being a carer. There was evidence of resistance among professional carers towards an introduction of information and communication technology applications in elder care. Carers considered that the same attributes of information and communication technology that could promote humane care could also lead to dehumanized care.

CONCLUSION

There should be an ethical discussion when introducing information and communication technology applications in elder care. The best caring alternative for all those concerned should be considered. It should promote aspects of wellbeing and dignity for frail older people and fears of inhumane care among carers must be recognized and discussed.

Supportive needs of parents confronted with sudden cardiac death--a qualitative study

The death of a close family member is one of life's greatest tragedies. When death is sudden and unexpected, there is an increased risk of posttraumatic reactions and complicated mourning. Care of the bereaved is still often overlooked in medical training and clinical practise. The aim of this study was to elucidate the perceived support and the needs of bereaved parents confronted with sudden cardiac death (SCD) in a young son or daughter. Data were derived from a qualitative contents analysis of tape-recorded, in-depth interviews with bereaved parents confronted with SCD 5-12 years post-loss. The 20 deceased individuals were part of the Swedish forensic SCD cohort of 15-35 year olds from 1992 to 1999. One third of the parents had had no contact with the emergency department (ED), one third had been disappointed after meeting care-givers at the ED who did not act with sensitivity and consistency, while one third were more or less satisfied with the handling at the ED. A majority of the parents experienced a lack of follow-up care; they had been left mainly to themselves to find information and support. Four factors were identified as being particularly important for the parents: evidence, reconstruction, explanation and sensitivity. There is a need of better routines to help the suddenly bereaved. A model of the major needs and a plan for the support needed are proposed.

Establishing joint attention in remote talks with the elderly about health: a study of nurses' conversation with elderly persons in teleconsultations

This study is a contribution to the sparsely studied field of nurses' teleconsultations with frail elderly people. The aim was to describe how talk and interaction are accomplished and by what means problems are handled that emerge from the fact that the communication is conducted via videoconferencing techniques. Recordings were made of 22 sessions of teleconsultation between nurses and elderly nursing home residents aided by enrolled nurses. The data were analysed with a qualitative method inspired by conversation and discourse analysis. The findings indicate that in order to create a joint attention the participants often had to verbally confirm and reconfirm that contact had been established. The triad of participants played a special part in maintaining the joint attention through compensating for the contextual aspect of the medium's limitations and the demented elderly person's communication problems. 'Talks about the communication' and passages of social talk took place when the nurse or the staff member wanted to re-establish and maintain joint attention. The joint attention seemed connected to a special sort of eye contact and gaze and to the type of camera projection that was used. One conclusion was that to create joint attention in nurses' teleconsultations with frail elderly people, the limitations in transferring communication cues and the limitations of what the camera can reveal of the general context could, to some extent, be made up for by verbal communication within the triad of participants. Another conclusion was that these limitations in the context of interaction in some situations also seemed to be an advantage for the demented elderly and contributed to increased attention.

Being present in a distant room: aspects of teleconsultations with older people in a nursing home

In a telecare project in Northern Sweden, videophones have been used to facilitate teleconsultations between nurses and elders at a nursing home. The authors designed this study to elucidate qualities in the communication in the professional encounter between nurses and elders assisted by nursing staff in the teleconsultations. They interviewed 2 registered nurses and 5 nursing staff members with long experience of using videophones in the telecare project, out of 20 staff members, and analyzed them using a phenomenological-hermeneutic method. In a comprehensive interpretation, teleconsultations could be understood as glimpses of the experience of being in the other's room with a feeling of providing nursing presence. This was attained when aspects such as familiarity, safety, transparency, and interest were promoted.

Promoting a good life among people with Alzheimer's disease

AIM

To illuminate the meaning of offering care and a place to live to people with Alzheimer's disease in a special care unit.

RATIONALE

There is a need to gain a deeper understanding about so called 'homelike' care settings, and about how to promote experiences of being at home in residents with Alzheimer's disease. The study is part of a long-term study in a special care unit.

METHODS

The study comprises phenomenological hermeneutic interpretation of interviews with 10 care providers.

RESULTS

The analyses revealed a number of caring aspects such as, for example, 'viewing dignity and striving to preserve a sense of self in the resident', 'encouraging a sense of belonging', 'offering relief' and 'promoting a sense of power and control in the resident', although integrated and reflected in each other. The caring aspects constituted the themes confirmation, familiarity, communion and agency considered as dimensions of the good life.

CONCLUSION

To avoid simplification in which, for example, the furniture from a certain decade become the standard for good care, it seems important to focus upon the meaning of the good life. Care that promotes a good life of people with Alzheimer's disease seemed relationship centred.

Narratives of care providers concerning picking behavior among institutionalized dementia sufferers

To illuminate the meaning of picking behavior in institutionalized people with dementia, the narratives of 15 care providers were interpreted using a method inspired by Ricoeur's phenomenologic hermeneutics. The care providers saw the behavior as a form of meaningful communication. The behavior was described as occurring in combination with wandering and in connection with restlessness and stress related to fatigue, difficulty communicating, and lack of occupation. The behavior also was seen as an attempt to engage in meaningful activities. Some care providers reported that the picking behavior caused them strain, whereas others reported a more positive reaction because the behavior made the ward more alive. Most care providers perceived the meaning of the picking behavior relative to the dementia sufferer's previous life and said they reacted by diverting, allowing, or understanding the picking.

The experience of being at home throughout the life span. Investigation of persons aged from 2 to 102

One hundred and fifty persons aged two to 102 narrated their experiences related to the phenomenon "being at home." Several common interdependent and interrelated aspects of the experience of being at home were identified throughout the life span. These aspects are believed to entail cognitive, emotional, and conative dimensions of the experience: safety, rootedness, harmony, joy, privacy, togetherness, recognition, order, control, possession, nourishment, initiative, power, freedom. The sense of being related was found to be a common condition of the experience of being at home, i.e., related to significant others, significant things, significant places, significant activities, oneself, and transcendence. In the process of maintaining the experience of being at home throughout life the phenomena "being given a home," "creating a home," "sharing a home," and "offering a home" were integral parts. A progression in the experience of being at home throughout the life span was identified.