The purpose of this study was to examine registered nurses' attitudes toward caring. The instrument used to measure nurses' attitudes was the Nyberg Caring Assessment Scale. The tool consists of a set of twenty statements asked four times to establish: a) ideal caring; b) actual caring; c) supervisor caring; and d) caring five years ago. A convenience sample of sixty three registered nurses from one midwestern hospital was used for this study. The surveyed registered nurses exhibited positive attitudes toward caring in today's cost containment healthcare system. There were significant correlation coefficients among the four sub-scales of caring. Results of this study have implications for nursing practice and nursing education. / School of Nursing

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This research focused on the life situation of older people, who had moved to a nursing home at the end of life, from the perspectives of the older people themselves, care managers and nursing staff. The thesis is based on an analysis of 446 care manager assessments and decisions, interviews with seven care managers, six older people and 28 nursing staff. The main fi ndings are: (I); that there was a statistically signifi cantly shorter waiting time for a move to a nursing home for older people who were in hospital compared to those who were living in their own home at the time of the decision. Seventy percent of the decisions made by care managers’ concerned women. The waiting period for men was fi ve days shorter compared to women. (II); that the care managers’ descriptions revealed that their assessments of the needs and wishes of the older people were infl uenced by whether or not it was clear that the older person had only a limited time left to live. The care managers’ way of reasoning has been conceptualised as two approaches, the medical and the natural path to death, where the former was characterised as fl exible and collaborative, whereas the latter was governed to a greater extent by a “wait and see attitude”. (III); that the older people’s experiences of living in a nursing home have been conceptualised into three themes: feeling like a stranger in an unfamiliar culture, being excluded from life, and living while waiting for death. The latter involved a deep insight that life would soon come to an end; a fact the staff appeared to take into account to only a minor extent. (IV); that dying and death was characterised by a discourse of silence, with tension between avoidance of and a confrontation with death. Staff members who expressed a fear of death held it at a distance by concentrating on practical tasks and avoiding close contact with older people who were dying. The thesis highlights the fact that the dying and death of older persons was characterised by a discourse of silence and several transitions. Death was not a topic that the staff members or older people generally talked about, and care in the fi nal phase of life was not actively or explicitly planned. In terms of access to a nursing home bed, only older people with an extensive need for care obtained such a place. These fi ndings imply that all older people can be said to be in need of palliative care. The older people in our study were in a liminal phase, and waiting for death. Feelings of social and existential loneliness and that their living space was shrinking were evident. It was also clear that the older people and staff members inhabit the same place but appear to be in two different sub-cultures, where the norms and values that guided the staff members’ attitudes were dominant. Keywords: transition, older people, end of life care, palliative care, nursing home, caring, care manager and staff

Aim: The overall aim of this thesis was to gain a deeper understanding of F-LNMs’ leadership. Another aim was to examine possible differences in self-rated health between F-LNMs and registered nurses (RNs) on various psychosocial factors. Method: Study I and III are single case studies. Study I concerns a first-line nurse manager working in a unit for care of older people. Data collection comprised of two interviews, observations, and documents. A hermeneutic approach was used for the analysis. Study II was carried out in three units at three Swedish hospitals. Three F-LNMs and 14 RNs participated. Interviews were used to collect data. The interviews were analysed using qualitative content analysis. Study III was conducted at a palliative care unit. Data were collected using three separate instruments: a questionnaire, group interviews with nurses and leaders, and documents. Qualitative content analysis was used to analyse the material. Study IV was conducted at a university hospital. Seventy-eight F-LNMs and their 1,806 subordinated RNs participated in the study. Data were collected using a web-based questionnaire (Web-QPS) to assess the participant’s psychosocial work environment and their self-rated health. Result: The main finding in study I was that the F-LNM goal-profile consisted of three goals - the nurse goal, the administrator goal and the leadership goal. The administrator and leadership goal were in accordance to her job description, while the nurse goal was interpreted as a personally chosen and prioritised goal. In study II the result was illustrated in one main theme referred to as between being and doing. The RNs and F-LNMs described what it was to be a good professional (being), how they were engaged in creating a good work climate (doing) and personal outcomes of this project (gaining). In study III the result showed that the most important component at the palliative care unit was to accomplish the vision of good palliative care. Congruence in leadership, mature group functioning, adequate organisational structures and resources, and comprehensive and shared meaningfulness were all identified as essential components for fulfilling the vision. In study IV both F-LNMs and RNs found their work in general important, interesting and meaningful and reported self-rated health as good. However, about 10-15% shoved signs of being at risk for stress related ill health. The results showed statistically significant differences in the distribution between the F-LNMs and the RNs on three indices: job control, job demand and managerial support in a direction which would be favorable to the F-LNMs. Conclusion: Nurses and F-LNMs seem to have high ideals and expectations of giving good care. The value- system of nursing, i.e. providing the best care for each patient, seems to be a point of departure for the F-LNMs leadership. Key factors for obtaining this are sufficient resources and adequate structures as well as good climate in the teams. One can therefore assume that the F-LNMs should be based on creating a healthy and sustainable work environment that promotes the quality of care and employee well-being. This is obtained by promoting development of ethical competence of the F-LNMs themselves as well as the employees. F-LNMs’ work conditions have a significant impact on how they can support and promote such a development. 

Health-related quality of life (HRQL) has become an important outcome in asthma, since traditional outcomes, such as respiratory symptoms and pulmonary function, might not entirely express the patient’s perception of the limitations caused by the disease. The aim of this thesis was to study HRQL in asthma and to analyse if HRQL was related to asthma onset and prognosis. Other aims were to identify determinants of low HRQL in clinically-verified asthmatics, and to study whether low HRQL was a predictor of mortality. In 1990, a self-administered questionnaire was completed by 12,560 individuals from three age groups (16, 30-39, and 60-69 years) in two counties of Sweden. In a second phase, all subjects who reported a history of obstructive respiratory symptoms (n = 1,851) and 600 randomly-selected controls were invited to a clinical investigation including spirometry, allergy testing, and assessment of HRQL with the Gothenburg Quality of Life instrument. In 2003, the eligible subjects in the cohort (n=11,282) were sent a new questionnaire. Mortality data in the cohort was followed up during 1990–2008 using data from the National Board of Health and Welfare Mortality Database. The 616 subjects with clinically-verified asthma 1990 had significantly lower HRQL than subjects without asthma. In the 2003 follow-up, the 305 subjects with persistent asthma had a lower HRQL than the 155 subjects who showed improvement in asthma during the follow-up. Subjects who had developed asthma by the follow-up had a significantly lower HRQL at baseline than those who did not develop asthma. Significant determinants of quality of life in asthma were female sex, smoking habits, higher airway responsiveness to irritants, respiratory symptom severity, positive skin prick test, and absenteeism from work or school. Low HRQL was related to increased mortality, but this association was not found when analyzing the asthmatic group alone. In conclusion, measurements of HRQL are of value for evaluating both the impact and progression of asthma.

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.

Thesis (M.I.T.)--The Evergreen State College, 2007. / Title from title screen viewed (4/10/2008). Includes bibliographical references (leaves 136-140).