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The aim of this thesis was to develop and make a quality assessment of a tool, which includes a questionnaire and a dialogue process that could be useful for workplace health promotion from a salutogenic point of view. The studies have been performed within two health care organizations between 2005 and 2009, together with hospital staff. Two questionnaire studies were conducted (n=446 n=505, respectively). A focus group interview study was performed (n=78), and meetings were held in an action research process for applying a questionnaire process at two wards (n=69). The result shows a development process for a multi-dimensional questionnaire, the Work Experience Measurement Scale (WEMS), which can be used to measure work experiences from a salutogenic perspective. WEMS was shown to be a functional workplace health promotion questionnaire with the ability to discriminate between groups. Its psychometric properties support its applicability in health care settings and offer a possibility to measure trends over time regarding employees´ work experiences. A dialogue structure for progress in the questionnaire process is presented. It describes what to precede and how to proceed through a workplace questionnaire process to foster applicability, meaningfulness, and sustainability. Through WEMS, the outcome of work-related Specific Enhancing Resources (SER) may be highlighted and strengthened in workplace activities. When used as a dialogue tool in a continuous questionnaire process, WEMS has the potential of being a useful assessment tool in workplace health promotion. Such a dialogue tool is useful in discussions and tangible for the work of enhancing positive human capabilities and resources (SER) that improve work performance.

Sammanfattning Bakgrund: Att drabbas av hjärt-eller hjärnsjukdomar i en ålder av 30 till 49 kan förändra livet radikalt. Tillvaron kan upplevas som kaotiskt, stressande och utmanande. Livet efter sjukdomen kan skapa fysiska och psykiska följdsjukdomar som behöver vårdas. Mål utifrån egna värderingarna och upplevd kompetens motiverar till handling. Det behövs olika former av stöd i syfte att finna livet begripligt, hanterbart och meningsfullt. Syfte: Syftet med studien är att utforska hur personer som drabbats av hjärt-och hjärnsjukdomar i en ålder av 30 till 49 upplever sin sjukdomshistoria och rehabilitering. Metod: För studien valdes en kvalitativ design där intervjuer genomfördes med åtta personer, både män och kvinnor. Datainsamlingen bestod av semistrukturerade intervjuer och analyserades med hjälp av kvalitativ innehållsanalys. Resultat: Tre kategorier framkom från analysen: Faktorer på individnivå (1) som innehåller underkategorierna ”health literacy” och ”livsvärderingar”; Stöd från omgivningen (2) som innehåller ”omsorg”, ”coacha” och ”professionell vård”; Leva i ny verklighet (3) som innehåller ”stress och hjärntrött”, ”identitet”, ”känslor och tankar som vägledande” och ”återgång till arbetet”. Ett tema steg fram ur intervjustudierna, ” Kroppsliga- och själsliga symtom behöver vårdas, så positiv energi kan frigöras till meningsfulla aktiviteter”. Kategorierna visar på viktiga hinder och möjligheter som påverkar ett hälsofrämjande rehabiliteringsarbete. Slutsats: Det behövs kunskap och ett coachande stöd i rehabiliteringen utifrån individens unika livssituation i syfte att uppleva större egenmakt och ökad upplevd hälsa. Den professionella rådgivaren behöver ha en bred kunskap, främja empowerment och inneha ett holistiskt hälsoperspektiv. Studien visar att ytterligare forskning om professionellt stöd är värdefullt både ur samhälls- och individperspektiv. Nyckelord: Coping, Empowerment, Hälsopromotion, Kris, Känsla av sammanhang / Abstract Background: To suffer from heart or brain diseases at the age of 30 to 49 can create an existential life crisis. Existence is experienced as chaotic, stressful and challenging.Life after the disease can create physical and mental complications that need to be treated. Objectives based on own values and perceived skills motivate action. People need different kind of support in order to find life comprehensible, manageable and meaningful. Aim: The aim of this study was to explore how people at the age of 30 to 49 have experienced their medical history and rehabilitation. Method: For the study, a qualitative design was chosen in which interviews were conducted with eight people, both men and women. The data collection consisted of semistructured interviews and was analyzed using qualitative content analysis. Results: Three categories emerged from the analysis: Individual-level factors (1) containing the subcategories 'health literacy' and 'life values'; Support from the environment (2) containing "care", "coach" and "professional care"; Live in new reality (3) containing "stress and brain fatigue", "identity", "feelings and thoughts as guiding" and "return to work". One theme emerged from the interviews, "Bodily and mental symptoms need to be looked after so that positive energy can be released into meaningful activities." The categories show important obstacles and opportunities that affect health-promoting rehabilitation work. Conclusion: There is a need for knowledge and coaching support in rehabilitation based on the individual's unique life situation in order to experience greater empowerment and increased health. The professional adviser needs a holistic approach towards health care and rehabilitation. The findings shows that further research about professional support is valuable both from a societal and individual perspective. Keywords Coping, Crisis, Empowerment, Health promotion, Sense of coherence

Background and objectives: Stress-related illness is a growing public health problem in Sweden and it is the most common reason for sick leave today. Stress-related illness causes suffering on a number of levels and affects the patient’s health and life in the long term. The stress-related ill health also leads to consequences for society, causing high costs for sick leave and health care as well as lost workforce since people partially or entirely lose their capacity to work. Research on stress-related ill health and rehabilitation often underline work-related conditions as crucial in dealing with the problem. There is also research that points out psychosocial factors in understanding stress-related ill health. What we know little about is the existential perspective of clinical burn-out. Therefore, it is of importance to investigate people’s existential experiences of clinical burn-out and the significance of an existential perspective in rehabilitation. Aim: The overall aim of this thesis is to gain insight into the existential experience of clinical burn-out as well as to highlight the significance of an existential perspective in rehabilitation. In addition, the thesis aims to reach a deeper understanding of clinical burn-out from an existential point of view and contribute to the field with knowledge of the existential dimension of health. Methods: The study, conducted in 2011, is based on qualitative interviews made with an inductive hermeneutic approach. Five patients and seven care givers were interviewed, focusing their existential experiences of clinical burn-out as well as their experiences of rehabilitation with an existential approach. A strategic selection was made of informants in the context of a rehabilitation program with an existential approach for people diagnosed with clinical burn-out. The data was analysed in two steps. In the first step the data was interpreted with an inductive hermeneutic approach. In step two of the analysis, the data was interpreted with a deductive hermeneutic approach, using Karl Jasper’s concept of limit situation as a way of interpreting the existential experience. Aaron Antonovsky’s concept sense of coherence was used as a tool for understanding components that can contribute to restoring health. Results: In this study, the patients describe clinical burn-out as a comprehensive existential experience that can be perceived as being in between life and death, in a shadow world, trapped in a dead end. It’s a situation characterized by being powerless. It creates a need to comprehend one’s situation in order to be able to regain control and manage it. It’s a struggle to make sense of the life situation. When not being met with understanding, the patients lose hope. Existential issues in terms of meaning, existence and life choices become urgent. Working with the existential perspective requires trust, openness from both caregiver and patient, distinctness, a way to communicate it and courage to take on the challenge of dealing with existential issues. The perspective also requires that the existential suffering can be contained. Dealing with existential questions leads to self-knowledge and insights that enables a possibility to make different choices and leave negative behavioural patterns. Also, it can lead to a discovery of spirituality and religion as a resource in life. Besides their personal struggle for meaning, the patients see an existential void in society, leaving people without tools to handle existential needs. This is understood as something that affects people’s ability to handle stressful times in life. The care providers understand burn-out as a manifestation of a way of living that is not sustainable. It is an existential experience embodied in body and mind that can be experienced as being drained of life. It’s an existential challenge, causing grief when realizing one’s limitations as a human being. Also, loss of meaning and sense of existential vulnerability due to an experience of being annihilated is crucial for understanding the deep existential crisis that clinical burn-out can induce. This situation makes the patient ask existential questions about identity, meaning, values and direction. In the burnout-process the patients have distanced themselves from their own self and therefore need to reconnect with themselves. This makes the existential questions central in the rehabilitation as a way to reconnect to inner strength and resources, which are prerequisites for starting a health promoting, sustainable process which is empowering, making it possible to see oneself as a human being who experience meaning, not only as a patient with a diagnosis. Instead of finding meaning in the diagnosis, the patient’s existential questions and the existential experience is a key to moving forward, out of the situation. Meaning-making is therefore important in the rehabilitation. A holistic-existential approach and view of man makes it possible to work with the complexity of the situation. The holistic-existential approach creates synergies and offers an extra tool both for the caregiver and the patient. Focusing on the patient’s resources and competence makes it possible to see the crisis as a way to learn from it. The existential perspective in health care and rehabilitation is enabled by competence, openness, reliance, empathy and respect when meeting the patient. It also requires courage to take on the challenge of dealing with existential issues. It can be hard for both the patient and the care giver to confront existential suffering. It is the responsibility of the care giver to enable the existential perspective by acknowledging and making the existential perspective possible to communicate and work it through. The care providers understands values in modern society as contributing to people’s experience of feeling alone with existential needs, which intensifies their existential aloneness. The care providers’ experience is that the biomedical paradigm aggravates an existential perspective. The perspective is not associated with the care situation. There is a lack of knowledge about and understanding of the value of the existential perspective, all the way from the decision-making level to the clinical meeting with the patient. In addition, the paradigm affects how the patients express their illness. Also, the perspective requires time. Existential perspectives, therefore, tend to be concealed in the health care context. Applying Karl Jasper’s concept of limit situation, clinical burn-out can be interpreted as a defining existential experience. It can be understood as a limit situation when humans realize their limitations and at the same time get insights that are crucial for their lives. It’s an experience they wish they had not gone through, but on the other hand, it has led to insights they do not want to be without. The meaning-making process is health promoting by recreating meaning, the fundamental part of sense of coherence, which is crucial for a salutogenic direction. Conclusion: The existential state that the clinical burnout patients go through can, using Karl Jasper’s concept, be understood as a limit situation. According to Jasper’s reasoning, the limit situation can be perceived as facing an abyss, making it clear one has limitations as a human being. At the same time, the experience can be perceived as reaching a limit where humans can get insights about human life that can enhance life. Clinical burn-out, using Aaron Antonovsky’s concept, can be understood as a loss of the components that create sense of coherence. Loss of meaning is particularly central for understanding burn-out. Consequently, it is crucial to acknowledge the existential challenge that the patient is facing, as well as the importance of the meaning-making process for facilitating a movement in a health promoting manner. It gives a deeper understanding of the challenges and needs of patients suffering from clinical burn-out. The existential dimension of health has been highlighted in health promotion, but gets little attention in practice. This is especially significant in the health care context. This points out the need for a discussion about how the existential health dimension can be used as a resource in health care and rehabilitation and how this resource for health can be applied in a better way in health promotion and public health.

Syftet med studien var att beskriva upplevelsen från vård- och återhämtningstiden hos patienter som vårdats på intensivvårdsavdelning. Metoden som används hade en kvalitativ ansats. Data samlades in via intervjuer med 11 patienter som vårdats på intensivvården från två sjukhus i Sverige. Materialet analyserades genom kvalitativ innehållsanalys. Resultatet blev fyra kategorier och 14 subkategorier. Kategorin Känna trygghet bestod av subkategorierna: Bli väl omhändertagen i vården, Få information och Vikten av stöd. Kategorin Förlust av kontroll innefattade: Sakna vetskap och förståelse, Fragmenterade minnen från vårdtiden, Overklighetsupplevelser samt Känna rädsla, obehag och smärta. Kategorin Stärkas av egna resurser inkluderade subkategorierna: Vikten av positiv inställning, Hoppas och drivas av framsteg samt Bra fysiska förutsättningar och intressen som drivkraft. Kategorin Erfara förändring bestod av subkategorierna: Känna fysisk svaghet, Komplikationer som påverkar ens tillvaro, Vilja leva som tidigare och Tankar kring livet.  Slutsatsen var att god omvårdnad inkluderade patienters behov av att bli sedda, behandlade med omsorg samt minnas och förstå vad som sker. Förståelse bygger på information om den egna sjukdomsbilden, komplikationer och återhämtning. Dessa behov belyser vikten av att i omvårdnaden utgå från patienterna och att integrera dem i vården.   Som vårdpersonal bör vi sträva efter att stärka patienters känsla av sammanhang vilket förutsätter att de är väl insatta i sin sjukdom, vård och behandling samt konsekvenser av det de går igenom.  Personcentrering är viktigt för patienters känsla av sammanhang och därmed deras hälsa och livskvalité under och efter sjukhusvård. / The aim of this study was to describe the experience from the hospital stay and time of recovery in patients admitted to intensive-care unit. The method used had a qualitative approach. Data was collected through interviews with 11 patients who had received intensive-care from two hospitals in Sweden. Data was analyzed with qualitative content analysis. The result was four categories and 14 subcategories. The category To feel secure included the subcategories: Good patient care, Receive information and The importance of support. The category Loss of control comprised of the subcategories: Lacking knowledge and understanding, Fragmented memories of the hospital stay, Experiences of unreality and To feel fear, pain and discomfort. The category Strengthen by their own resources included the subcategories: Importance of positive attitude, To hope and be driven by success and also Good physical conditions and activities as the driving force. The category Experience changes contained the subcategories: Feel physical weakness, Complications that affects your life, Wish to live as before and Thoughts about life.  The conclusion was that good nursing care included patient’s needs to be seen, treated with care and remember and understand what was happening. Understanding was based on information about their own illness, complications and recovery. These needs highlights the importance of basing nursing care on the patient and to integrate them in their own care and treatment. Health professionals should strive to strengthen the patient’s sense of coherence which implies that they are well versed in their illness, care and treatment and consequences of what they are going through. Person-centering is important for the patient’s sense of coherence and thus their health and quality of life during and after hospitalization.

Bakgrund: Cancer är idag en vanlig sjukdom och vid sidan av en person med cancer finns närstående som kan riskera att glömmas bort. Att vara närstående kan vara en påfrestande upplevelse och riskerar att leda till ohälsa. Närstående bör involveras i vården och deras välmående bör tas hänsyn till. Syfte: Studiens syfte var att beskriva de närståendes upplevelse av stöd som fenomen, när en person i deras närhet drabbats av cancer. Metod: En deduktiv litteraturöversikt med KASAM som teoretisk utgångspunkt. För att besvara syftet användes kvalitativa artiklar. Sökningar i CINAHL gjordes och resulterade i 16 resultatartiklar. Resultat: Närstående upplevde den nya livssituationen som ofattbar, information kring sjukdom och behandlingsmöjligheter från vårdpersonal gjorde situationen mer begriplig. De närstående använde olika strategier för att anpassa sig till situationen och fann stöd i vänner och familj. Att närvara vid behandlingar ledde till delaktighet i vården vilket gjorde att de närstående upplevde ett syfte. Slutsats: Genom stöd kan en känsla av sammanhang upplevas trots närvaro av sjukdom. Att som närstående bli sedd och lyssnad till underlättar för att hantera den nya situationen och att finnas där för den sjuka personen. / Background: Cancer is a common disease and is often associated with death, although the treatments are getting better and the number of survivals is growing. In the shadow of a person with cancer there will always be loved ones who should not be forgotten.    Aim: The aim of the study was to describe the next of kin’s experience of support as a phenomenon, when a loved one is affected with cancer. Method: A deductive literature review with sixteen qualitative articles was made, using Sense of Coherence [SOC] as a theoretical approach. Searches for result articles was made in CINAHL. Result: Relatives experienced the new life situation as unimaginable, information from healthcare staff about the disease and possibilities of treatment made the situation understandable. Relatives used different strategies to adjust to the new situation and found friends and family to be a source of support. Being present during treatment gave the relative a sense of purpose. Conclusion: With support a sense of coherence can appear even in the presence of disease. To be seen and listened to makes it easier for the next of kin to handle the new situation and be able to be there for the ill person.

Bakgrund: Obstruktiv sömnapné (OSA) är en vanlig och mycket utbredd sjukdom förknippad med betydande hälsoproblem, samsjuklighet och mortalitet. De flesta vuxna med OSA är utan diagnos och behandling. Primärvårdens distriktssköterskor spelar en viktig roll vid identifiering och vägledning av patienter med misstänkt OSA. Syfte: Syftet var att beskriva distriktsköterskans erfarenheter av att identifiera och vägleda patienter med misstänkt OSA inom primärvården. Metod: En kvalitativ ansats i form av en kvalitativ manifest innehållsanalys genomfördes där sju distriktssköterskor intervjuades. Analysprocessen genomfördes enligt Graneheim och Lundmans innehållsanalys. Resultat: I studien framkom fem kategorier: att möta patienten, att ställa rätt frågor, anhörig som motivator, att vidta åtgärder och att samverka med övrig vård. Distriktssköterskorna beskrev att de mötte patienterna med misstänkt OSA oftast antingen via telefonrådgivning eller på diabetesmottagningen. Deltagarna i studien belyste att det var viktigt att ställa rätt frågor till patienter och känna till de vanliga tecknen på OSA. Det framkom även att anhöriga hade en viktig roll vid identifiering av patienter med misstänkt OSA och fungerade som motivator. I studien upptäcktes även strävan efter att vägleda patienter med misstänkt OSA. Slutsats: För att underlätta arbete med OSA patienter i primärvården behövs forskning med fokus på distriktssköterskor samt gemensamma riktlinjer för utredning av patienter med misstänkt OSA anpassade för primärvårdspersonal. / Background: Obstructive sleep apnea (OSA) is a common and very spread disease associated with significant health problems, comorbidity and mortality. Most adults with OSA are without diagnosis and treatment. Primary care district nurses play an important role in identifying and guiding of patients with suspected OSA. Purpose: The purpose was to describe the district nurse's experience of identifying and guiding patients with suspected OSA in primary care. Method: A qualitative approach in the form of qualitative manifest content analysis was conducted where seven district nurses were interviewed. The analysis process was conducted according to Graneheim and Lundman's content analysis. Result: The study revealed five categories: to meet the patient, to ask the right questions, relative as motivator, to take workarounds and to interact with other care. District nurses described that they met the suspect OSA patients most often by telephone counseling or at the diabetes reception. The participants in the study illuminated the importance of how to ask the right questions to patients and to know the common signs of OSA. It was also found that relatives had an important role in identifying of patients with suspected OSA and they worked as motivators. The study also identified the strain for guiding patients with suspected OSA. Conclusion: In order to facilitate work with OSA- patients in the primary care, research is needed which is focusing on district nurses and common guidelines for investigating of patients with suspected OSA adapted for primary care staff.

<p>The purpose of this study was to investigate and expand the knowledge of how bereaved spouses in palliative care handled their grief. Attempts were also made to distinguish common patterns among the experiences that the bereaved spouses expressed.  Furthermore the study aimed to understand how the bereaved spouses handled their grief, and to understand what helped them to move on. A qualitative method was used in this essay, related to the purpose of investigating the spouses’ emotional experiences. The questions used to reach an understanding of the matter were: How did the bereaved experienced their grief? Were there important contributing factors worsening their grief or making it easier? How did the bereaved persons handle their grief, and what helped them to work things through and carry on with their lives? The result was analyzed by using Antonovsky’s theory; <em>a feeling of coherence, Lazarus’ <em>coping theory combined</em></em> with Folkman’s <em>revised </em>coping theory<em>.</em> The results were also analyzed by the findings of <em>continuing bonds </em>derived from Ainsworth’s <em>attachment theory. </em>The seven strategic picked out respondents in this study, constituted from a development project, financed by Cancerfonden, which took place in the palliative unit of Stockholms sjukhem in 2007. The results showed that the sense of coherence had an effect on the bereaved spouses’ way to handle their grief. The respondents’ ability of awareness and mental preparation were significant. As it turned out, the time extent of the disease did not have a major effect on the bereaved spouses’ experience of their grief. Furthermore the study showed that the context was very significant, and that the bereaved spouses to a great extent used positive reappraisal.</p><p><p><p> </p><p> </p><p> </p><p> </p></p></p>

<p>Ill health is unevenly distributed across different groups in society, with the disadvantaged groups displaying higher rates of ill health than the more advantaged groups. The aim of the thesis is to study work-related inequalities in health, and to focus on how income, aspects of the physical and psychosocial work environment, and sense of coherence, individually or jointly, generate inequalities in a number of health outcomes in the Swedish working population. The studies are based on survey data and national registers during the period 1990-2003.</p><p>For cardiovascular disease (CVD) prevalence and mortality, the impact of income was stronger than that of work environment factors. The psychosocial work environment (women and men) and income (men only) were associated with psychological distress. Income (women) and the psychosocial work environment (men) were associated with musculoskeletal pain. Thus, both income and work environment are important in generating health inequalities in the working population.</p><p>A strong sense of coherence (SOC) moderated the effect of physical demands on musculoskeletal pain in both genders. SOC moderates, yet not consistently, the impact of adverse working conditions on psychological distress and musculoskeletal pain. Hence, the results do not fully support the hypothesis that sense of coherence is a global health-protective factor. However, differential vulnerability in terms of the strength of SOC contributed to work-related inequalities in health.</p><p>The risk of stroke was higher for women and men in occupations with low job control than for those with high job control. The risk of intracerebral hemorrhage was highest in women in low job-control occupations, while low job control did not significantly increase the risk of brain infarction in women. Job control was related to mortality from stroke in women, but not in men. The effect of job control on stroke mortality in women was consistent in all classes except for upper non-manuals.</p>

<p>The purpose of this study is to investigate the young caregivers thoughts of the elderly caretaker. A qualitative method was chosen when interviewing young caregivers in order to get an insight of how they perceive and speak of the elders. The main questions of the study are: How do the caregivers believe that the elders perceive their day-to-day life and situation? Is it possible to distinguish if the young caregiver’s thoughts about the elders affect their work with the elderly caretaker? Is it possible to notice any common factors that the young caregivers perceive as important in their work with the elderly caretaker? The criteria for inclusion in this study are caregivers aged 18 to 25, who are working with elderly at special accommodation. The theories chosen for this study are the salutogenetic perspective, the activity theory and the theory of gerotranscendence. From the outcome of the study the conclusion is that the interaction between the elder and the caregiver seem to be decisive for how the young caregiver think of the elders and their life situation. The caregivers in this study experience that activities give the elderly a meaningful life.</p>