SAMMANFATTNINGBakgrund: Hjärtsvikt är i Sverige en folksjukdom där cirka 200 000 personer beräknas lida av symtom och lika många till lever utan några symtom. Under de nästkommande 25 åren beräknas inläggningar att öka med 50% då prevalensen av hjärtsvikt ökar på grund av befolkningstillväxten, åldrande och den ökade förekomsten av samsjuklighet. Sjuksköterskeledda hjärtsviktsmottagningar inom primärvården verkar vara effektiva för att tillhandahålla högkvalitativ personcentrerad vård och därmed minska behovet av sjukhusvård. Personcentrering är en process att ta tillvara patientens resurser med hänsyn till individens förutsättningar och hinder. Ett partnerskap som bygger på ömsesidig respekt, är jämbördig och inbjuder till delaktighet och att vårdtagaren får den information som behövs för att kunna fatta rätt beslut. Syfte: Att belysa sjuksköterskors erfarenheter av hur de arbetar utifrån ett personcentrerat förhållningssätt med personer med hjärtsvikt i primärvården.Metod: En kvalitativ semistrukturerad intervjustudie med induktiv ansats där nio sjuksköterskor deltog som arbetade på hjärtsviktsmottagningar. En kvalitativ innehållsanalys användes och det teoretiskt ramverk utgick från ett personcentrerat förhållningssätt. Resultat: Innehållsanalysen resulterade i fyra huvudkategorier holistisk människosyn, individuellt bemötande, partnerskap och delegering av läkemedel. Slutsats: I resultatet framkom att alla sjuksköterskor ansåg sig lyssna till personens berättelseoch att de utgick delvis från en helhetssyn, men det fanns brister i att tillgodo se de existentiella behoven. De tyckte sig erbjuda individanpassad vård och behandling efter personens förutsättningar och behov och de upplevde att det var en viktig del i arbetet att motivera till delaktighet i egenvård samt kunskap och förståelse om sjukdomen. Sjuksköterskorna önskade bli bättre på att inkludera anhöriga. Få sjuksköterskor hade delegering av läkemedel och några få tyckte att det hade betydelse för omhändertagandet. / ABSTRACTBackground: In Sweden, heart failure is a common disease, where approximately 200,000 people are estimated to suffer from symptoms and the same number live without any symptoms. Over the next 25 years, admissions are projected to increase by 50% as the prevalence of heart failure increases due to population growth, aging and the increased prevalence of comorbidities. Nurse-led heart failure clinics in primary care appear to be effective in providing high-quality person-centred care and thereby reducing the need for hospitalisation. Person-centredness is a process of making use of the patient's resources, taking into account the individual's conditions and obstacles. A partnership that is based on mutual respect, is equal and invites participation and that the care recipient receives the information needed to be able to make the right decision.Aim: To shed light on nurses' experiences of how they work based on a person-centred approach with people with heart failure in primary care.Method: A qualitative semi-structured interview study with an inductive approach in which nine nurses who worked in heart failure wards participated. A qualitative content analysis was used and the theoretical framework was based on a person-centred approach.Results: The content analysis resulted in four main categories: holistic view of people, individual treatment, partnership, delegation of medicines.Conclusion: The results showed that all nurses considered themselves to listen to the person's story and that they partly started from a holistic view, but there were shortcomings in satisfying the existential needs. They seemed to offer individually tailored care and treatment according to the person's conditions and needs, and they felt that it was an important part of the work to motivate participation in self-care as well as knowledge and understanding of the disease. The nurses wanted to be better at including relatives. Few nurses had delegation of medicines and a few thought it was important for care.

Hjärtsvikt är ett mycket vanligt tillstånd och kan innebära nedsatt livskvalitet, frekventa sjukhusinläggningar och hög dödlighet. En viktig del i behandlingen vid hjärtsvikt är utförandet av egenvård, vilket innebär att vidta åtgärder för att upprätthålla hälsa. På senare tid har utvecklingen och användningen av digitala verktyg som stöd till egenvård ökat. Genom olika digitala mobilapplikationer och fjärrövervakningssystem kan personer med hjärtsvikt stödjas i utförandet av egenvård, vilket kan leda till förbättrat hälsotillstånd och minskat antal sjukhusinläggningar.  Syftet var att beskriva upplevelser av att använda digitala verktyg som stöd till egenvård hos personer med hjärtsvikt.  Metoden var en litteraturöversikt med systematisk sökstrategi och genomfördes i enlighet med Polit och Beck´s niostegsmodell. Utifrån databassökningar i CINAHL och PubMed inkluderades 18 artiklar med kvalitativ metod eller mixad metod. Artiklarna kvalitetsgranskades och analyserades sedan genom en integrerad analys.  Resultatet baseras på 18 artiklar som bedömts ha god kvalitet eller mycket god kvalitet. I resultatet framkom att deltagarna upplevde att de digitala vertygen kunde öka deras kunskap och förståelse för egenvård, öka deras motivation till egenvård och stärka deras egenmakt. De använde de digitala verktygen som stöd för att övervaka tecken och symtom på försämring och som stöd för att vidta egenvårdsåtgärder. De digitala verktygen upplevdes av många som användbara och enkla att använda, men det framkom också svårigheter med användningen som exempelvis fysiska begränsningar, bristande digital kompetens och tekniska problem.  Slutsatsen är att de digitala verktygen upplevdes användbara för att upprätthålla egenvårdsbeteenden, övervaka tecken och symtom som kan tyda på försämring och som stöd vid beslut om egenvårdsåtgärder. Deltagare beskrev dock även en del svårigheter med användningen. / Heart failure is a very common condition and can involve reduced quality of life, frequent hospitalizations and high mortality. An important part of the treatment for heart failure is the performance of self-care, which means taking measures to maintain health. Recently, the development and use of digital tools as support for self-care has increased. Through various digital mobile applications and remote monitoring systems, people with heart failure can be supported in self-care, which can lead to improved health status and reduced hospital admissions. The aim was to describe experiences of using digital tools as support for self-care in people with heart failure. The method was a literature review with a systematic search strategy and was carried out in accordance with Polit and Beck's nine-step model. Based on database searches in CINAHL and PubMed, 18 articles with a qualitative method or mixed method were included. All articles were quality checked and then analyzed through an integrated analysis. The result is based on 18 articles judged to have good quality or very good quality. The result showed that the participants felt that the digital tools could increase their knowledge and understanding of self-care, increase their motivation for self-care and strengthen their empowerment. They used the digital tools to support monitoring for signs and symptoms of deterioration and to support taking self-care measures. The digital tools were perceived by many as useful and easy to use, but there were also difficulties with their use. The perceived difficulties were mainly related to physical limitations, lack of digital skills and technical problems. The conclusion is that digital tools were found useful in maintaining self-care behaviors, monitoring signs and symptoms that may indicate deterioration, and supporting decisions about self-care measures. However, participants also described some difficulties with the use.

This thesis is about cultural aspects of advanced medical technology for treating end-stage heart failure. New medical technologies like mechanical help-hearts save lives, but they also bring new uncertainties, risks, and challenges. Based on nine months of ethnographic field work in a Swedish academic hospital, this study examines the ways of managing uncertainties of end-stage heart failure and of high-tech treatment, and also how these practices tie into the shared understandings of life-threatening chronic illness, the body, and medical technology’s role. This study draws on anthropological discussions of healing rituals as an analytical tool to make sense of social and cultural dimensions of mechanical help-heart implantation treatment. Viewed as a ritual, this treatment creates and maintains hope as a virtue through which possibilities of new medical technology are justified as culturally approved ways of handling the uncertainties of severe heart failure and mechanical help-heart treatment. Ultimately, even when treatment is regarded as successful, the patients may be saved but are never really ‘cured’ and remain, thus, permanently tied to the world of medicine. This new mode of existence is characterized by paradoxical permanent transit between uncertainty and hope. / Avhandlingen fokuserar på de kulturella aspekterna av den medicinska teknologin som används vid behandling av svår hjärtsvikt. Samtidigt som ny medicinsk teknologi som mekaniska hjälphjärtan räddar liv för den även med sig ovisshet och nya utmaningar som ofta är svåra att förutse. Baserat på nio månaders etnografiskt fältarbete vid ett universitetssjukhus i Sverige undersöks hur denna ovisshet och dessa utmaningar hanteras av medicinskt personal och patienter. I avhandlingen behandlas också sambanden mellan medicinska praktiker och de lokalt delade uppfattningarna om livshotande kroniska sjukdomar, den mänskliga kroppen och teknologins roll. Utifrån diskussioner inom antropologin om ’helande ritualer’ analyseras i avhandlingen de sociala och kulturella aspekterna av behandling med mekaniskt hjälphjärta. Studien visar att genom de rituella aspekterna av denna behandling, genereras och upprätthålls hoppet som en dygd. Den nya medicinska teknologins möjligheter rättfärdigas på så sätt som ett kulturellt accepterat sätt att hantera ovissheten vid svår hjärtsvikt och behandling med mekaniskt hjälphjärta. Även vid lyckade behandlingar, då patienternas liv räddas, blir de trots allt inte riktigt ’botade’ utan förblir bundna till den medicinska världen. Detta nya levnadssätt karakteriseras av en paradoxal och livslång balansgång mellan ovisshet och hopp.

Introduction The prevalence of depressive symptoms in persons with heart failure is higher than in age- and gender-matched populations not suffering from heart failure. Heart failure in itself is associated with an unpredictable trajectory of symptoms, a poor prognosis, high mortality and morbidity, and low health-related quality of life (HrQoL). With the addition of depressive symptoms to heart failure the negative health effects increase further. Though the negative consequences of depressive symptoms in heart failure are well known, there is a knowledge gap about the course of depressive symptoms in heart failure and about how to effectively manage these symptoms. Pharmacological treatment with serotonin reuptake inhibitors has not been able to demonstrate efficacy in persons with heart failure. In a few studies, cognitive behavioural therapy (CBT) delivered face-to-face, has demonstrated effects on depressive symptoms in persons with heart failure. However, currently there are barriers in delivering face-to-face CBT as there is a lack of therapists with the required training. As a solution to this, the use of Internet-based CBT (ICBT) has been proposed. ICBT has been shown to be effective in treatment of mild and moderate depression but has not been evaluated in persons with heart failure. Aim The overall aim of this thesis was to describe depressive symptoms over time and to develop and evaluate an ICBT intervention to treat depressive symptoms in persons with heart failure. Design and Methods The studies in this thesis employ both quantitative (Studies I, II and III) and qualitative (Studies II and IV) research methods. The sample in Study I (n=611) were recruited in the Netherlands. The participants (n=7) in Study II were recruited via advertisements in Swedish newspapers. Studies III and IV used the same cohort of participants (Study III n=50, Study IV n=13). These participants were recruited via an invitation letter sent to all persons who had made contact with healthcare services in relation to heart failure during the previous year, at the clinics of cardiology or medicine in four hospitals in southeast Sweden. Study I had a quantitative longitudinal design. Data on depressive symptoms was collected at baseline (discharge from hospital) and after 18 months. Data on mortality and hospitalisation was collected at 18 and 36 months after discharge from hospital. Study II employed three differentBehind the Screen2patterns of design, as follows: I) The development and context adaptation of the ICBT program was based on research, literature and clinical experience and performed within a multi-professional team. II) The feasibility of the program from the perspective of limited efficacy and function was investigated with a quantitative pre-post design. III) Participants’ experience of the ICBT program was investigated with a qualitative content analysis. Data on depressive symptoms was collected pre and post intervention. The time used for support and feedback was logged during the intervention, and qualitative interviews were performed with the participants after the end of the intervention. Study III was designed as a randomised controlled trial. A nine-week ICBT program adapted to persons with heart failure and depressive symptoms was tested against an online moderated discussion forum. Data on depressive symptoms, HrQoL and cardiac anxiety was collected at baseline (before the intervention started) and after the end of the intervention (approximately 10 weeks after the start of the intervention). Study IV had a qualitative design to explore and describe participants’ experiences of ICBT. The participants were recruited from within the sample in Study III and all had experience of ICBT. Data collection occurred after the ICBT program ended and was carried out using qualitative interviews by telephone. Results The mean age of the samples used in this thesis varied between 62 and 69 years of age. Concerning the symptom severity of heart failure, most persons reported New York Heart Association (NYHA) class II (40-57%) followed by NYHA class III (36-41%). Ischaemic heart disease was the most common comorbidity (36-43%). The vast majority had pharmacological treatment for their heart failure. Six percent of the persons in Study I used pharmacological antidepressants. In Studies II and III, the corresponding numbers were 43% and 18% respectively. Among persons hospitalised due to heart failure symptoms, 38% reported depressive symptoms. After 18 months, 26% reported depressive symptoms. Four different courses of depressive symptoms were identified: 1) Non-depressed 2) Remitted depressive symptoms. 3) Ongoing depressive symptoms. 4) New depressive symptoms. The highest risk for readmission to hospital and mortality was found among persons in the groups with ongoing and new depressive symptoms. A nine-week ICBT program consisting of seven modules including homework assignments on depressive symptoms for persons with heart failure was developed and tested. The RCT study (Study III) showed no significant difference in depressive symptoms between ICBT and a moderated discussion forum. Within-group analysis of depressive symptoms demonstrated a significant decrease of depressive symptoms in the ICBT group but not in the discussion forum group. The participants’ experience of ICBT was described in one theme: ICBT- an effective, but also challenging tool for self-management of health problems. This theme was constructed based on six categories: Something other than usual healthcare; Relevance and recognition; Flexible, understandable and safe; Technical problems; Improvements by live contact; Managing my life better. Conclusion After discharge from hospital, depressive symptoms decrease spontaneously among a large proportion of persons with heart failure, though depressive symptoms are still common in persons with heart failure that are community dwelling. Depressive symptoms in persons with heart failure are associated with increased risk of death and hospitalisation. The highest risks are found among persons with long-term ongoing depressive symptoms and those developing depressive symptoms while not hospitalised. ICBT for depressive symptoms in heart failure is feasible. An intervention with a nine-week guided self-help program with emphasis on behavioural activation and problem-solving skills appears to contribute to a decrease in depressive symptoms and improvement of HrQoL. When ICBT is delivered to persons with heart failure and depressive symptoms the participants requests that the ICBT is contextually adapted to health problems related to both heart failure and depressive symptoms. ICBT is experienced as a useful tool for self-care and something other than usual healthcare. ICBT also requires active participation by the persons receiving the intervention, something that was sometimes experienced as challenging.

Följande studie behandlar utvecklandet av automatiserade cellsegmenteringsmodeller med avsikt att identifiera gränser mellan celler i hjärtvävnad. Syftet är att möjliggöra analys av data genererad från multiplexed error-robust in situ hybridization (MERFISH). MERFISH är en spatial transcriptomics-teknik som till skillnad från exempelvis single-cell RNA sequencing (ScRNA-seq) och single molecule fluorescence in situ hybridization (smFISH), möjliggör profilering av hundratals RNA-sekvenser hos enskilda celler utan att förlora dess rumsliga kontext. I Kosuri laboratoriet på Salk Institute of Biological Studies i San Diego tillämpas MERFISH på mushjärtan. Syftet är att få en djupare insikt i hur celler är organiserade i friska hjärtan, och hur denna struktur ändras i och med åldring och sjukdom. Att extrahera meningsfull information från MERFISH medför dock en betydande utmaning - en exakt cellsegmentering. Studien bidrar följaktligen till utvecklandet av segmenteringsmodeller för att kringgå de utmaningar som står i vägen för all efterföljande analys. Då klassiska segmenteringsalgoritmer är otillräckliga för att segmentera den komplexa vävnad som hjärtat utgörs av, tillämpades några av dagens mest avancerade och framstående maskininlärningsalgoritmer inom fältet, kallade Cellpose och Omnipose. Givet den täta och heterogena hjärtvävnaden, som härstammar från en bred distribution av celltyper och geometrier, utvecklades två separata modeller; en för att täcka både mindre celler och kardiomyocyter skurna på tvärsnittet; och en för att enbart segmentera kardiomyocyter skurna i longitudinell riktning. Den förstnämnda modellen utvecklades och tränades i Cellpose, och uppnådde en träffsäkerhet på 91.2%. Modellen för longitudinella kardiomyocyter utvecklades istället både i Cellpose och Omnipose för att utvärdera vilket nätverk som är bäst lämpat för ändamålet. Ingen av nätverken lyckades uppnå en tillräckligt hög träffsäkerhet för att vara applicerbar, och är därmed i behov av fortsatt träning. Modellen genererad i Omnipose bedöms dock vara mest lovande, givet dess mer heltäckande segmentering. Ytterligare utvecklingsområden för framtiden innefattar segmentering av celler i fibros-täta regioner, samt att utveckla en 3D-segmentering av hela hjärtat för att uppnå en mer komplett MERFISH-analys. Sammanfattningsvis har de genererade segmenteringsmodellerna banat väg för möjliggörandet av en rigorös MERFISH-analys av hjärtat. Genom att avslöja några av de strukturella och funktionella orsakerna till hjärtsvikt på en cellulär nivå, kan vi således på sikt bidra till utvecklingen av mer effektiva terapeutiska strategier. / The following study delves into the development of automated cell segmentation models, with the intention of identifying boundaries between cells in the cardiac tissue for analysing spatial transcriptomics data. Addressing the limitations of alternative techniques like single-cell RNA sequencing (ScRNA-seq) and single molecule fluorescence in situ hybridization (smFISH), the study underscores the innovative use of multiplexed error-robust fluorescence in situ hybridization (MERFISH) deployed by the Kosuri Lab at Salk Institute for Biological Studies. This advanced imaging-based technique allows for a single-cell transcriptome profiling of hundreds of different transcripts while retaining the spatial context of the tissue. The technique can accordingly reveal how the organization of cells within a healthy heart is altered during disease. However, the extraction of meaningful data from MERFISH poses a significant challenge - accurate cell segmentation. This thesis therefore presents the development of a robust model for cell boundary identification within cardiac tissue, leveraging some of the advanced supervised machine learning algorithms in the field, named Cellpose and Omnipose. Due to the dense and highly heterogeneous tissue- stemming from a wide distribution of cell types and shapes- two separate models had to be developed; one that covers the smaller cells and the cross-sectioned cardiomyocytes, and correspondingly one to cover the longitudinal cardiomyocytes. The cross-section model was successfully developed to achieve an accuracy of 91.2%, whereas the longitudinal model still needs further improvements before being implemented. The thesis acknowledges potential areas for improvement, emphasizing the need to further improve the segmentation of longitudinal cardiomyocytes, tackle the challenges with segmenting cells within fibrotic regions of the diseased heart, as well as achieving a precise 3D cell segmentation. Nonetheless, the generated models have paved the way towards enabling efficient downstream MERFISH analysis to ultimately understand the structural and functional dynamics of heart failure at a cellular level, aiding the development of more effective therapeutic strategies.

The Swedish government and the Swedish Association of Local Authorities and Regions, cametogether on a vision that Sweden will be the most advanced country in offering opportunities fordigitalization and e-health by the year of 2025. Self-monitoring is one aspect that can digitizeworkflow in healthcare. This master thesis sought to investigate the opportunities and restrictions when implementingself-monitoring for heart failure patients in Swedish healthcare. Starting from the holisticperspective as an analysis of the clinician’s interest and the need for self-monitoring systemsby conducting a mixed method approach. Surveys were sent out to different county councilsin Sweden working with heart failure patients, and interviews were conducted withrepresentatives from primary care, specialist care, and advanced home health care. Secondly,interviews were conducted with stakeholders from the field of implementation in order togather qualitative results on the organizational, legal, and technical influencing factors,challenges, and requirements in Swedish healthcare. The qualitative data were processedthrough thematic analysis and the quantitative data was processed through descriptive analysis. The results gathered from clinicians consisted of three areas regarding functionality demandsin self-monitoring systems. The results gathered in the aspect of implementation consisted ofthree main organizational influencing aspects, three solution models from a legal perspective,as well as three aspects related in the field of technology and IT. / Sveriges regering och SKR gick samman om en vision om att Sverige ska vara det land somhar kommit längst med att erbjuda möjligheter till digitalisering av vård till år 2025. Egenmon-itorering är en aspekt som kan digitalisera arbetsflöden i vården. Detta masterarbete ämnade att undersöka möjligheter och begränsningar vid implementeringav egenmonitorering för hjärtsviktspatienter i svensk sjukvård. En mixad metodinriktninggenomfördes, som delades upp i två huvudsakliga delar. Första delen ämnade sig till kliniker,där enkäter skickades ut till olika landsting i Sverige som arbetar med hjärtsviktspatienter,samt intervjuer som genomfördes med representanter från primärvård, specialistvård ochavancerad hemsjukvård. Den första delen ämnade till att undersöka klinikers intresse ochbehov av egenmonitorering. Den andra delen bestod av intervjuer med ämnesexperter inomimplementation och digitalisera system för svensk sjukvård. Intervjuerna medimplementationsexperterna genererade kvalitativa resultat utifrån ett organisatoriskt, juridisktoch tekniskt perspektiv. Den kvalitativa datan bearbetades genom en tematisk analys och den kvantitativa datanbearbetades genom en deskriptiv analys. Resultaten som samlats in från kliniker bestod av treområden avseende funktionalitetskrav i egenmonitoreringssystem. Resultaten som samladesin gällande implementationen i svensk sjukvård bestod av tre huvudsakliga organisatoriskapåverkande aspekter, tre lösningsmodeller ur ett juridiskt perspektiv, samt tre aspekterrelaterade till teknik och IT.

Heart failure is a term for a group of complex symtoms characterized by reduced heart function. One of these syndromes, referred to as heart failure with preserved ejection fraction (HFpEF), has increased in prevalence compared to other types of heart failures during the recent years. A concern is the difficulty in diagnosing patients with HFpEF, since current tools are considered insufficient. The aim of this thesis was to examine Peak Oxygen Uptake (VO2peak) in relation to Total Heart Volume (THV) among heart failure patients with preserved ejection fraction (HFpEF, EF >40 %) compared to healthy controls. THV was acquired by delineating images acquired using cardiovascular magnetic resonance imaging, while VO2peak was measured in oxygen curves acquired from cardiopulmonary exercise tests. Ratios were calculated by dividing VO2peak with THV. In order to determine if blood hemoglobin concentration (b-Hb) could affect the ratio, ratios were adjusted to b-Hb using an adjusting factor. Mean THV was nearly 250 ml larger in HFpEF patients compared to the controls. Patients’ mean VO2peak was more than 1000 ml lower compared to the controls. Mean VO2peak/THV ratio calculated for the patients were less than half of that calculated for the controls. Adjusting the ratio to b-Hb did not affect the ratios significantly. The study was limited by the size of the test group, but the findings suggest that a VO2peak/THV ratio can be used to separate HFpEF patients from healthy controls. / Hjärtsvikt är ett begrepp för en grupp med komplexa symtom och kännetecknas av försämrad hjärtfunktion. Ett av dessa syndrom, hjärtsvikt med bevarad ejektionsfraktion (HFpEF), har ökat i prevalens jämfört med andra varianter av hjärtsvikt under de senaste åren. Ett problem är de svårigheter som finns med att diagnosticera patienter med HFpEF, då nuvarande verktyg inte är tillräckliga. Syftet med detta examensarbete var att undersöka maximalt syreupptag (VO2peak) i förhållande till total hjärtvolym (THV) bland hjärtsviktspatienter med bevarad ejektionsfraktion (HFpEF, EF >40 %) jämfört med friska kontroller. THV erhölls genom att utlinjera bilder tagna med hjälp av magnetisk resonanstomografi, medan VO2peak mättes i syrevolymkurvor som registrerats under ergospirometri-undersökningar. Index beräknades genom att dividera VO2peak med THV. För att undersöka huruvida halten hemoglobin i blodet (b-Hb) kunde påverka index justerades index mot b-Hb med hjälp av en justeringsfaktor. Medel-THV var nästan 250 ml större hos HFpEF-patienter jämfört med kontroller. Medel-VO2peak var mer än 1000 ml lägre hos patienterna jämfört med kontroller. Medel VO2peak/THV-index som beräknats för patienter var mindre än hälften så högt som index beräknat för kontroller. Att justera index mot b-Hb påverkade inte index signifikant. Studien begränsades av mängden deltagare, men fynden indikerar att VO2peak/THV-index kan användas för att skilja HFpEF-patienter från friska kontroller.

Heart failure is a growing public health problem associated with significant morbidity and mortality. Family support positively affects outcomes for the person with heart failure while also leading to caregiver burden. Registered nurses have a key role in supporting and meeting the needs of family caregivers. The overall aim was to explore the situation and needs of family caregivers to a person with heart failure, and explore requisites and ways of supporting and involving family caregivers in heart failure nursing care. Two interview studies, one web survey study and one intervention study were conducted between 2012 and 2017. A total of 22 family caregivers, eight persons with heart failure and 331 registered nurses participated in the studies. Family caregivers' daily life was characterized by worry, uncertainty and relational incongruence but salutogenic behaviours restored new strength and motivation to care. Family caregivers experienced that their caregiving was taken for granted by health care professionals. Family caregivers expressed a need for a permanent health care contact and more involvement in the planning and implementation of their near one’s health care together with health care professionals. Registered nurses acknowledged family caregivers’ burden, lack of knowledge and relational incongruence. A registered nurse was suggested as a permanent health care contact to improve continuity and security. Registered nurses neither acknowledged family caregivers as a resource nor their need for involvement. Registered nurses working in primary health care centres, in nurse-led heart failure clinics, with district nurse specialization, with education in cardiac nursing care held the most supportive attitudes toward family involvement in heart failure nursing care. Family health conversations via telephone in nurse-led heart failure clinics were found to successfully support and involve families. The conversations enhanced nurse-family relationship and relations within the family. They also provided registered nurses with new, relevant knowledge and understanding about the family as a whole. Family health conversations via telephone were feasible to both families and registered nurses, although fewer and shorter conversations were preferred by registered nurses. This thesis highlights the divergence between family caregivers’ experiences and needs, and registered nurses’ perceptions about family caregivers’ situation and attitudes toward the importance of family involvement. It adds to the knowledge on the importance to acknowledge family caregivers as a resource and to support and involve them in heart failure nursing care. One feasible and successful way is to conduct Family health conversations via telephone in nurse-led heart failure clinics.