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The discussion of a palliative care and a dignified death has almost exclusively been applied to people dying of cancer. As people are getting older and are living longer, nursing homes have become an important place for end-of-life care and death. Dignity is a concept often used in health care documents but their meaning is rarely clarified. The main aim of this thesis was to gain a deeper understanding of what dignity meant to older people in end of life care as well as to nursing home staff. The thesis comprises four studies. The first and second study involved older people living in nursing home settings studied from a hermeneutic perspective. In the first study twelve older people in two nursing homes were interviewed two to four times over a period of 18–24 months during 2002–2003. Altogether, 39 interviews were analyzed by a hermeneutic method. Dignity was closely linked to self-image and identity. The themes of unrecognizable body, dependence and fragility constituted threats to dignity. The third theme, inner strength and sense of coherence, seemed to assist the older people in maintaining dignity of identity. In the second study the aim was to acquire a deeper understanding of how three older women from study I, created meaning in everyday life at the nursing home. A secondary analysis was carried out and showed meaning in everyday life was created by an inner dialogue, communication and relationships with others. The third study was to explore nursing home staff members’ experience of what dignity in end-of –life care means to older people and to themselves. Totally 21 interviews with staff were carried out and analyzed through a qualitative content analysis. The meaning of older people’s dignity was conceptualized as feeling trust, which implied being shown respect. Staff members’ dignity was conceptualized as maintaining self-respect. Dignity was threatened in situations where staff experienced themselves and the older people as being ignored and thereby marginalized. The fourth study was carried out through focus groups discussions with 20 staff members about seven older peoples dying death and care. The analyses showed that conversations and discussions about death were rare. Death was surrounded by silence. It was disclosed that the older dying person’s thoughts and attitudes of death were not explicitly known. A dignified death meant alleviation of bodily suffering and pain and meaningfulness. The staff’s ethical reasoning mainly concerned their experience of a gap between their personal ideals of what a dignified end of life should include and what they were able to provide in reality, which could result in conscious stress. Staff members need training and support. End of life care demands competence and teamwork. A challenge for future care of older people would be to develop a nursing home environment in which human dignity is promoted. / Hemmet som den sista vårdplatsen

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ABSTRAKT Kvinnors tillfredsställelse med mödrahälsovården (MHV), påverkas av olika faktorer, dels av kvinnornas egna förväntningar inför födandet, amningen och föräldraskapet, som bland andra vi som barnmorskor är med och skapar, dels av faktorer av organisatorisk karaktär. Syftet med denna studie var att beskriva kvinnors tillfredsställelse med MHV samt att studera om denna förändrats över tid. En enkätstudie utfördes vid Sundsvalls sjukhus före och efter införandet av eftervård för nyförlösta kvinnor på vårdhotell år 2005. Under dessa år genom¬fördes även vissa organisatoriska förändringar inom MHV för Medelpad- Ångermanland. Studien är epidemiologisk, icke-experimentell och deskriptiv med retrospektiva jämförelser av data från två kohorter föräldrapar, 2004 respektive 2006. En beräkning av relativa risker med 95 % konfidensintervall och en logistisk regressionsanalys av de signifikanta variablerna med beräkning av oddskvot för tillfredsställelsen gjordes. Resultatet visade att de viktigaste faktorerna för tillfredsställelse med helheten av MHV var att få stöd av barnmorskan, att få information om graviditeten, förlossningen och tiden efter förlossningen, samt att inte få färre besök än enligt gällande basprogram. Det fanns en minskad tillfredsställelse med helheten av MHV mellan åren 2004 och 2006. Resultatet genererar ett behov av förbättrat stöd, samt en upprepad mätning av tillfredsställelsen med MHV inom enheten. Nyckelord: Barnmorskor, enkäter, hälsoupplysning, mödravårdscentraler, psykosocialt stöd, socialt nätverk.

The proportion of elderly people in Sweden is increasing. Many of these live at home and as their age increases so does the likelihood of health problems and the need for support, medical attention and care. Personnel working with home help provide a large part of this care, including areas of home-based care that are the responsibility of the district nurse. The purpose of this paper is to describe how home-help personnel perceive their work in the area of home-based care, as their views are an important factor in the ability to provide a care system that funktions successfully. The method employed here is phenomenografic and nine subjects from a home-help group have been interviewed. The results show that the subjects do not perceive home-based care as being a part of their work, despite the responsibility that they take upon themselves by performing tasks that are intrinsically part of the work area home-based care. The results also show that they are competent in skills they are not permitted to use, and that the district nurse takes responsibility, is competent, and partakes in the home-based care, but from a distance. The conclusions that can be drawn here are that the home-help personnel’s work includes more aspects of home-based care than they themselves are aware of and that they draw upon themselves responsibility for certain elements of home-based care in the home because they are present during the provision of care whereas the district nurse is not. Keywords: Home-help service, home care, aged, phenomenography. / Andelen äldre människor i Sverige ökar. Många bor kvar i sina hem och med stigande ålder ökar risken för hälsoproblem och behov av både service, vård och omsorg. Det är hemtjänstpersonalen som utför en stor del av dessa insatser, inklusive det som tillhör hemsjukvården och som distriktssköterskan har ansvar för. Syftet med den här uppsatsen är att beskriva hemtjänstpersonalens uppfattningar av sitt arbete i hemsjukvården, kunskap som är viktig för en fungerade vård och omsorg där hemtjänstpersonalen är betydelsefull. Metoden som används är fenomenografisk och nio informanter från en hemtjänstgrupp har intervjuats. Resultaten visar att informanterna inte uppfattar hemsjukvård som sitt arbete trots ansvaret de tar för insatser som tillhör hemsjukvårdens område. Det som också framkommer är att de har kompetens som de inte får använda sig av och att distriktssköterskan tar ansvar, är kompetent och deltar i hemsjukvården, men på ett frånvarande sätt. Slutsatserna är att hemtjänst-personalens arbete innehåller mer hemsjukvård än de själva uppfattar och att de tar ansvar för delar i hemsjukvården eftersom de är närvarande i vårdandet, vilket inte distriktssköterskan är. Nyckelord: Hemtjänst, hemsjukvård, äldre, fenomenografi.

The aim of this thesis is to study prevalence of winter depressive mood and treatment effects of bright light for persons with winter fatigue and winter depression. Study I is a cross-sectional survey of a random sample (N=1657) from the general population between 18-65 years of age in Dalarna, Sweden (latitude 60°N). Study II is a similar survey of 17-18 year old students (N=756) in the municipality of Falun. Approximately 20% of both samples report seasonal symptoms, mainly fatigue, lowered mood and increased sleep duration, appetite and weight. Study III examines the effects of treatment in light rooms for persons from the sample in Study I (40 women, 10 men) with clinically assessed Seasonal Affective Disorder (SAD) or subclinical SAD (S-SAD). Subjects were randomised either to an experimental group receiving ten days of bright light treatment or to a three-week waiting-list control condition followed by bright light treatment. There was a >50% reduction of depressed mood in 13 of the 24 subjects in the experimental group, while none of the 24 controls reported a similar reduction. At the one-month follow-up, results were maintained and 39 of 47 subjects were improved >50%. Fatigue and excessive daytime sleepiness, which were high at baseline, were normal/below population norms for 39 of 47 subjects at the one-month follow-up. Mean values for the mental health aspect of health-related quality of life, which were low at baseline, improved and were close to norms at the one-month follow-up. Study IV is a person-oriented subgroup/cluster analysis of the subjects in Study III. A common trait in all three clusters was a high level of fatigue hence the denomination ´Winter Fatigue´ is used for the merged group. Even though the degree of depressive mood and daytime sleepiness differed between the subgroups, all three groups improved following bright light treatment. The results suggest that an increase in fatigue and depressed mood during the winter season is common in the general population. Bright light treatment reduces depressive mood, fatigue and excessive daytime sleepiness and improves health-related quality of life in persons with winter fatigue and winter depression.

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