Stroke is one of the major causes of eating difficulties (EDs). It is one of the leading causes of death and disability and one of the most important factors contributing to health-care costs. There is a clear association between EDs after stroke and undernutrition, where studies have shown that structured screening of eating function among stroke patients can predict nutritional problems as well as need for subsequent institutional care. Reliable and valid instruments that can identify EDs exist, but there is lack of knowledge on how persons experience living with EDs after stroke. Stroke unit care is evidence-based and grounded in multidisciplinary collaboration and continuity of care. The overall aim of this thesis is to explore and describe EDs after stroke as represented by health care professionals in patient records (PRs) and transferred information, and as described by persons living with EDs after stroke. An additional aim is to explore methodological aspects related to the inclusion of persons with EDs and communication impairment in research studies. Both quantitative and qualitative methods were used. Two studies used descriptive designs (I, II), one an explorative design (III) and one applied a methodological discussion (IV). In one of the studies PR data were used (I), in another study data were derived from three sources: PRs, screening of patients and interviews with nurses (II). Persons with EDs after stroke participated in Study III while literature, empirical data and researchers' experiences served as the data in study IV. Data were analysed by categorisation of phrases (I), content analysis (II) and descriptive statistics (I, II), by qualitative analysis (III) and by processing of literature and empirical findings in two research groups (IV). The main findings from the studies on representation of stroke care in PRs (I, II) showed that, despite that >50% of patients in Study I and all patients in Study II had EDs, there were few signs of multidisciplinary collaboration dealing with this problem. Unsystematic screening for swallowing difficulties was routine, whereas screening for nutritional risk and EDs was lacking (I, II). Multidisciplinary discharge summaries proved to have low quality and entailed little information on patients' eating ability (I). The two EDs most frequently documented were swallowing and lack of energy to complete a meal (I,II). EDs were described in vague terms (I, II). In Study II, all patients had swallowing difficulties and most patients had lack of energy to complete a meal. The electronic information transfer tool held information on eating ability for most patients (II), but the nursing staff in residential home care perceived deficiencies in that information, even identifying several EDs not reported at discharge (II). Experiences from persons living with EDs after stroke were presented in one main theme: Striving to live a normal life, including three sub-themes: Abandoned to learn on one's own (little support from health care professionals to learn to handle eating), Experiencing losses (loss of eating functions and loss of valued activities) and Feeling dependent in mealtime situations (III). One major finding from the methodological exploration (IV) is that creative approaches and suitable methods for inclusion of participants with EDs and communication impairment into qualitative studies can be found in the fields of aphasiology and learning disabilities. Another major finding from Study IV is that researchers need good communication skills as well as knowledge in neuropsychology. A general conclusion is that screening for EDs should be routine in stroke care and that a multidisciplinary terminology to express EDs must be developed to provide accurate information transfer. Health care professionals need to enhance their knowledge in nutrition and provide support to stroke patients with EDs with the goal that they can eat and perform meal-related activities in accordance with their habits before the stroke. To gain access to the experiences of persons with EDs and communication impairment researchers need to test participatory approaches when planning for inclusion of those persons.

Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the quality of documentation of patient care in nurses' notes in a home health agency in central Texas. A retrospective audit of quality of nursing documentation using the Nurse and Midwifery Content Audit Tool (NMCAT) was done. A pre- and posttest design was used. A convenience sample of de-identified nurses' notes (80 pre- and 80 post) was selected from active patient records in the agency (n = 160). Descriptive and inferential statistics from the project showed that there was improved quality for the 15 criteria representing quality nursing documentation. After the educational intervention, documentation of patient's status if changed or unchanged improved to 80%, and patient's response to treatment improved (57% to 85%), entries were written as incidents occurred improved (53% to 64%). The nurse refers to the patient by name improved (0% to 66%). These findings were an indication of practice change, validating the need for periodic audits of nurses' notes in the agency in order to demonstrate compliance with quality standards. Based on the project findings, a retraining program is recommended to improve structured nursing documentation in a home health agency. This project is likely to contribute to social change as it enhanced the information communicated to other health care providers, coordination of care, and patient outcomes.

Bakgrund: Patienter med kronisk obstruktiv sjukdom (KOL) som behandlas med Non-invasiv ventilation (NIV) har risk för trycksår och malnutrition. Observation och övervakning av patienterna är viktigt för att kunna följa behandlingsförloppet och tidigt upptäcka en eventuell försämring samt förebygga komplikationer. Dokumentation av given omvårdnad måste kunna följas för att utvärdera och säkerställa kraven på en god och säker vård. Syfte: Syftet med studien var att granska omvårdnadsdokumentationen för patienter med KOL som behandlats med NIV på en medicinsk akutvårdsavdelning. Metod: Studien genomfördes som en retrospektiv systematisk journalgranskning i 75 journaler med en granskningsmall. Resultat: Omvårdnadsprocessens steg fanns inte dokumenterad i sin fullständighet för trycksår eller nutrition i någon journal. Dokumentationen av omvårdnadsprocessen för trycksår var oberoende av antal vårddygn, kön och ålder men beroende av antal dygn med NIV.  För nutrition var dokumentationen av omvårdnadsprocessen beroende av antal NIV- och vårddygn men oberoende av kön och ålder. Dokumentationen för omvårdnad och behandling med NIV var utspridd i journalen under olika rubriker. Slutsats: Studiens resultat visade att det fanns brister i omvårdnadsdokumentationen.