This project explored the values considered by elderly people, their younger relatives, and health professionals in decisions about residential long - term care, aiming to contribute to the literature on prospectively held values. The mixed methods design utilised a medical record review of 60 frail elderly hospital patients, a stratified survey of 3,015 adults in the South Australian community, and interviews with 36 stakeholders ( 10 elderly people, 10 younger relatives, and 18 health professionals ). The medical record review confirmed that the hospital patients and their outcomes resembled those described internationally. It was used to develop a hypothetical vignette, used in the later studies. Survey responses suggested that when considering a hypothetical long - term care decision, community members put the elderly person ' s physical health and safety first. Situational variables ( the elderly person ' s autonomy, environmental adaptation, and caregiver burden ) appeared secondary, albeit less so with increasing age of the respondent. Thematic analysis of the interviews demonstrated that elderly stakeholders considering a hypothetical decision were more likely to mention autonomy values, and less likely to mention safety values, than were relatives or health professionals. However, elderly stakeholders were also more likely to suggest restrictive solutions, such as residential placement and proxy decision - making. This finding raised methodological issues concerning ' third person ' vignettes, in that respondents might be responding as proxy decision - makers, rather than as if the hypothetical decision applied to themselves. The project confirmed that, in this context, prospectively held values resembled the retrospectively described values identified by McCullough, Wilson, Teasdale, Kolpakchi and Shelly ( 1993 ). Hence, the retrospective literature could be applied. The project supported the importance and complexity of psychosocial predisposing factors when applying the Andersen Behavioral Model ( Andersen, 1995 ) to long - term care decisions. Additionally, the Ecological Theory of Aging ( Nahemow, 2000 ) and the MacArthur Model of Successful Aging ( Andrews, Clark, & Luszcz, 2002 ) were found to be relevant to long - term care decisions for individuals and populations. It was concluded that both clinically, and at a policy level, discussions of long - term care could be more effective if they focussed on maintenance of elderly people ' s autonomy and control, rather than on their physical health and safety. / Thesis (Ph.D.) -- University of Adelaide, School of Psychology, 2006.

Syftet: Syftet med studien var att beskriva hur omvårdnadspersonal inom kommunens särskilda boende och korttidsboende upplever att vårda personer i livets slutskede.Metod: Studien bygger på åtta kvalitativa intervjuer med undersköterskor. Datainsamlingsmetoden baserades på Critical Incident Technique och som analysmetod användes kvalitativ innehållsanalys. Resultat: I intervjuerna framkom att samarbetet till de övriga i teamet och närstående hade en stor och avgörande betydelse för hur vården utvecklades. Omvårdnadspersonalen kände ibland att sjuksköterskan saknades i vissa omvårdnadssituationer. Fördelning av personal under dygnet bidrog till kontinuitet i samverkan. De upplevde att olika faktorer i miljön kunde vara både till hjälp eller till hinder i samspelet till den döende och närstående. De intervjuade talade också om vikten av att respektera patientens vilja. Omvårdnadspersonalen gav även stöd till de närstående och de kom familjerna nära. De upplevde att närvaro utan krav och stress var av betydelse för interaktionen till den döende och dess närstående. Det var viktigt att både den döende och de närstående var tillfreds med symtomlindringen. Det var viktigt att få ge ett värdigt omhändertagande efter döden. Slutsats: Det genomgåendet temat visade att interaktion och samverkan med vårdteamet, närstående och patienten var av avgörande betydelseför hur vården i livets slut skulle bli trygg och värdig. / Aim: The aim of this study was to describe how the nursing staff within themunicipality's special housing and short term care perceived their caring forpatients receiving palliative care.Method: The study is based on eight interviews with enrolled nurses. The datacollection method was based on the Critical Incident Technique. The analysis ofinterviews was carried out with qualitative content analysis.Result: Cooperation between the care team and the relatives had a great andsignificant impact on how care was delivered. At times the nursing staff felt thatthe nurse was not present during various nursing interventions. Distribution ofstaff during the day contributed to the continuity of the interaction. The enrollednurses expressed that different environmental factors were either helpful orobstacles in the interaction between the dying person and their relatives. Theenrolled nurses illuminated the importance of respecting the patient's wishes. Thenursing staff provided the families with support which contributed to a feeling ofcloseness. Furthermore, the enrolled nurses felt that their presence withoutdemands and stress were significant in the interaction between the dying personand their family. It was important that the dying patient and their families weresatisfied with symptom control. It was significant to provide a dignified treatmentafter death.Conclusion: The overall theme was that the nursing staff perceived that interactionand collaboration between the care team, family and the patient was of significantimportance for a secure and dignified end of life care.

This study aims to understand how care managers approach consent and user influence related to older people with dementia. The study was conducted through qualitative interviews with individual care managers and with a hermeneutic approach. We have interviewed ten care managers in smaller municipalities whom are experienced in their profession and have been in contact with older people with dementia. throughout all the interviews, we had a semi-structured interview guide at our disposal, and after all the interviews were conducted, we analyzed them with the hermeneutic circle and theoretically analyzed the material with Lipsky´s theory about street level bureaucracy, acting space and, what we call it, the social service as a last resort and finally with Johansson´s theory of client relationships. Our main conclusions regarding consent is that care managers need to relate to the law simultaneously have the individual needs and wishes in regards. Also, the care managers have a few ways to circumvent the absolute that the individual needs to give his or hers consent to everything. Our main conclusions regarding user influence is that the care managers need to use other professions for information regarding the individual, such as nurses, carers, dependants and so on. They also prefer to get in touch with the individual whom is diagnosed with dementia as early into the disease as possible to get to know them and learn how they want their care to be. As a last conclusion about the whole study is that the care managers find working with older people with dementia is a vastly difficult task, and they need to rely on dependants, other professions and have a lot of knowledge about the individual.

Äldreomsorgen är en sektor som står inför stora utmaningar på grund av det ökade antalet äldre i kombination med svårigheter vad gäller rekrytering och kompetensförsörjning. För att klara av denna utmaning har en större kommun i södra Sverige undersökt alternativa kompetenser inom området och funnit att undersköterskans kompetens kan frigöras genom att omfördela arberbetsuppgifterna vad gäller service. Genom att serviceuppgifterna istället överförs till en ny yrkesroll, så kallad Vårdnära servicetjänster, kan detta komma att lösa delar av kompetensförsörjningen. Den rådande arbetsmarknaden, som präglas av rekryteringssvårigheter, sammanfaller med att det finns personer som står långt ifrån arbetsmarknaden. I vår kvalitativa intervjustudie har vi genomfört två enskilda intervjuer med personer som är väl insatta i ämnet samt genomfört en fokusgruppsintervju för att undersöka hur yrkesverksamma, som på daglig basis arbetar med att stötta personer att hitta sin plats på arbetsmarknaden, uppfattar den nya yrkesrollen. För att analysera vårt empiriska material har vi använt oss av tre teoretiska utgångspunkter vilka är Human Relations perspektivet, begreppet kompetens samt den objektivistiska pluralismen. I resultatet framkommer generellt att yrkesrollen kan komma att bli aktuell för de personer som av olika anledningar ännu inte hittat sin plats på arbetsmarknaden. Det har även framkommit andra tydliga vinster i kombination med vissa utmaningar som behöver tas i beaktande i det fortsatta arbetet med den nya yrkesrollen. I kommunen där studien utförts är yrkesrollen i dagsläget inte verksam och därför blir det en utmaning att diskutera dess framtida funktion och införandeprocess. Engelsk titel: Care Services- An opportunity for change? Nyckelord: äldreomsorg, Vårdnära servicetjänster, kompetens, rekrytering, Human Relations perspektivet, den objektivistiska pluralismen. / Elderly care is a sector facing major challenges due to the increased number of elderly people in combination with difficulties regarding recruitment and providing competence. In order to cope with this challenge, a larger municipality in southern Sweden has examined alternative competencies in the area and found that the competence of the assistance nurse can be released by redistributing the duties regarding service. Due to the fact that service duties instead are transferred to a new profession, called Care Services, this may solve a part of providing competence. The current labor market, which is characterized by recruitment difficulties, coincides with the fact that there are people far from the labor market. In our qualitative interview study, we have conducted two individual interviews with individuals who are well aware of the subject and we have also conducted a focus group interview in order to examine how professionals, who work on a daily basis to support people find their place in the labor market, perceive the new profession. In order to analyze our empirical material we have used three theoretical starting points, which are the Human Relations perspective, the concept of competence as well as objectivity pluralism. In general, the results show that the new profession may be relevant to those persons who for various reasons have not yet found their place in the labor market. There have also been other clear profits combined with certain challenges that need to be taken into account in the future work with the new profession. In the municipality where the study was conducted, the new profession is not yet active and therefore it is challenging to discuss its future function and the implementation. English title: Care Services- An opportunity for change? Keywords: elderly care, Care Services, competence, recruitment, Human Relations perspective, The objectivity pluralism.

In recent decades, the Swedish welfare system has been characterized by the increasing occurrence of market solutions. One example of this development is the introduction of voucher systems in the elderly care. With the purpose to contribute empirically based knowledge about elderly caretaker’s ability to act in a voucher system, interviews have been conducted with eleven relatives to someone who lives in a residential home. By further focusing on the unique features of the elderly care and putting these in relation to Albert O. Hirschman's concept of exit and voice, several conclusions have been made about the individuals strategies towards the voucher system. The study shows that the individuals relation to the voucher system is characterized by emotions and social relations witch complicates the ability to act rationally towards the market.  The unique character of the elderly care also means that the possibilities for exit (to change residential home when not content) are limited, as it implies a heavy burden for both relatives and caretakers to change residential home. Lack of information about what other options are available also limits the individuals ability to exit. The possibilities of voice (to protest and try to improve the quality of the care) are also limited to the individual as this is an option that takes a lot of energy and dedication. The study shows that protracted voice without improvement ultimately makes the individual give up his attempts to influence the quality of the care. The only option that remains when neither voice or exit is available is for the relative to personally take over the care of the caretaker.

The aim of this study was to understand how care managers in elderly care relate to self-determination when encountering older people with dementia. The study was conducted through qualitative interviews with a hermeneutic approach. We interviewed eight care managers experienced in working with older people with dementia. While interviewing we used a semi-structured interview guide. The material from the interviews were then analyzed through a hermeneutic circle and then theoretically analyzed by the use of Kant’s duty ethics, Bentham’s consequence ethics (normative ethics) and Foucault’s definition of power. Our main conclusions were that older people's self-determination is important and a legal right that clarifies that the power shall lie with the older person. Self-determination is, despite being a legal right, difficult to interpret in practice when it comes to older people with dementia. Depending on which ethical duty care managers lean on and what consequences that might bring, the decisions may differ. Sometimes older people's self-determination is unconditional, but sometimes the municipality’s final responsibility for older people is more authorized than older person's right to self-determination. Power within the relationship between care managers and older people with dementia is dynamic and care managers sometimes have to use their power in order to prevent danger. Our conclusion is that care managers find it difficult motivating departures from self-determination, since there is no coercive in Swedish legislation towards older people with dementia. Self-determination is therefore difficult to handle and requires well-balanced assessments, sometimes on the verge of what is considered as coercive.

This study aims to explore how male auxiliary nurses relate with gender-coded norms and why they relate to these norms in their work at elderly-care, while also exploring what kind of masculine identities appear when they relate to the expected gender norm. The empirical material was gathered by using a qualitative approach through semi-structured interviews with seven male auxiliary nurses from three different municipalities in Sweden. By using Connells (2008) masculinity-theory, where gender is seen as a process where the male body is regarded as an object and an acting organ which produces gender differences, this theory will help the essay understand the problems surrounding how the male auxiliaries’ nurses relate and negotiate with gender-coded norms in their work at elderly-care. This dynamic aspect of masculinity and the relation with the gender-structure will be used to examine how male auxiliary nurses relate and negotiating with different form of masculinities. The results of this study have showcased the evidently traditional gender norm that exists within this line of work, as the informants could relate to the pressure in maintaining their masculine identity. In some cases, the traditional gender norms have given the informants advantages and disadvantages which will be thoroughly explained later in the essay. The data ultimately showcased the dynamic and complex structure of masculinity, as male auxiliary nurses are expected to behave within the traditional forms of masculinity while also creating a new form of masculinity as they assume their “feminine” profession.

Abstract The purpose of this study was three-fold: to analyze how the work-relatedness of well-being has been constructed by the presently prevailing work stress approach, to develop better ways of conceptualizing the work-relatedness of well-being on the basis of cultural historical activity theory, and to test these new conceptualizations with empirical data from two nursing homes for the elderly. An analysis of the development of work stress theory and previous studies of nursing homes showed that their foundations lie in the paradigmatic person – environment formulation which inhibits taking into account the activity of the individual, the changing of the work process and the specific context in which stress is experienced. With respect to work-related well-being two activity-theoretical hypotheses were developed: the object-dependedness of work-related emotions (object-dependent well-being) and the increased physical and psychological work load as a result of disturbances in the flow of work (disturbance load). An empirical analysis of the historical development of the two nursing homes showed how the function of the nursing homes had changed several times and continued to do so. The analysis also suggested that changes in the work-related well-being of the employees followed the developmental phases of the work activity. The second empirical analysis showed how the employees' explanatory models of both tiring- and strength- giving events were related to several historical, present and possible future aspects of the object of their work. Signs of individual motive development could be detected in the interviews. The third empirical analysis of videorecorded morning routine episodes showed how the current institutional script carried out by the employees collided with the residents' own script resulting in resident resistance which increased the physical and psychological workload of the employees. Focusing on disturbance load may uncover important sources of emotional distress and physical tiredness among employees. Understanding work-related well-being also as qualitatively developing object-dependent well-being points to the need to create a dialogue between the development of the collective activity and the object and motive development of individual employees.

Market reforms have quite notably been used as a solution to increase the quality of public services and efficiency since the 1990s. Sweden has also introduced marketisation in the field of elderly care since 1992 to cope with increasing care needs while maintaining costs at a reasonable level. Yet, the introduction of a market mechanism in the welfare state is subject to increasing political and public debates. Many are sceptical about the purported benefits of a market, such as increased quality and reduced costs, as proposed by New Public Management. There have also been increasing critiques of the profit-making in care services in recent years. After two decades of marketisation, it is worthwhile to map out local politicians’ attitude patterns, namely, how they perceive the use of a market or quasi-market in a welfare state, where the market mechanism might challenge traditional principles such as universalism, solidarity, and equality. Complementary to studies on attitudes of public welfare, this research uses a unique survey dataset from 2014 to expand current understandings of politicians’ perspectives of marketisation. To be more specific, this study analyses three different aspects of marketisation: production, regulation, and financing. The results show that attitudinal differences between left- and right-wing politicians on private for-profit providers remain distinct. Political orientations of individuals, political majority in municipalities, and the privatisation level already achieved locally are identified as important factors in explaining local politicians’ willingness to privatise further. The preference differences continue to exist between the two blocs, and political ideology plays a major role in explaining these differences, more so than individual factors such as age, gender, or working position. Self-reported answers reveal that political ideology influences attitude formation. To a large extent, left- and right-wing politicians agree on welfare principles such as universalism, and they both recognise potential impacts that the market could have on society, such as inequality. It seems plausible that welfare state pluralism is the direction of the future. This case study serves as a solid example for examining the market development of public welfare in advanced welfare states and also contributes to the discussion of the potential role of political ideology in post-austerity welfare reforms. / Marknadsreformer har i ökande grad använts som en lösning för att öka effektiviteten och kvaliteten på offentliga tjänster sedan 1990-talet. I Sverige har också en gradvis marknadsanpassning ägt rum från tidigt 1990-tal med syfte att klara av ökade vårdbehov och för att upprätthålla kostnaderna på en rimlig nivå. Införandet av marknadsmekanismer i välfärdsstaten har blivit föremål för en livlig offentlig debatt. Många debattörer har varit klart skeptiska till de påstådda fördelarna med en marknadsanpassning, såsom förbättrad kvalitet och reducerade kostnader, som bland annat hävdats av New Public Managementskolans anhängare. Samtidigt har också skett en växande kritik av vinstuttagen och vinsttillväxten inom offentligfinansierad vård och omsorg de senaste åren. Efter två årtionden av marknadsanpassning är det motiverat att kartlägga lokalpolitikernas attityder, avseende hur de ser på den ökande marknadsanpassningen av den traditionella välfärdsstaten, där marknadsmekanismen kan utmana principer som universalism, solidaritet och jämställdhet. Förutom tidigare analyser av attityder beträffande offentlig välfärd är denna studie baserad på en unik enkätundersökning riktad till svenska kommunpolitiker genomförd 2014 i syfte att undersöka politikernas syn på de ökade marknadsinslagen inom offentlig äldreomsorg. Studien analyserar tre olika aspekter av marknadsanpassningen: produktion, reglering och finansiering. Resultatet visar att skillnaderna i attityder mellan vänster - och högerpolitiker avseende inslaget av privata vinstdrivande tjänsteleverantörer är mycket tydligt. Individernas politiska tillhörighet, politisk majoritet i kommunerna och privatiseringsnivån identifieras som viktiga faktorer för att förklara lokala politikernas villighet att öka privatiseringsgraden ytterligare. Det finns tydliga preferensskillnader mellan de två blocken och den politiska ideologin spelar en övergripande roll, medan individuella faktorer som ålder, kön eller politisk position spelar en klart mindre roll. Att ideologin är viktig konfirmeras även av politikernas självskattning avseende vilken betydelse olika faktorer har haft för deras attityder. I hög grad finns en samstämmighet mellan vänster- och högerpolitiker avseende välfärdsprinciper som universalism, och både blocken anser att marknaden kan bidra till ökad ojämlikhet i samhället. Det verkar troligt att välfärdsstatspluralismen är riktningen för framtiden. Denna fallstudie kan utgöra ett exempel för studier av marknadsanpassning i offentlig välfärd i avancerade välfärdsstater. Studien kan också bidra till diskussioner om den politiska ideologins potentiella roll för reformer av välfärdsstaten.

Aim: The overall aim of the thesis was to explore and describe registered nurses’ (RNs) and certified nursing assistants’ (CNAs) experiences of detection and assessment of pain in older people with cognitive impairment and dementia. A further aim was to evaluate the Abbey Pain Scale-SWE (APS-SWE) in dementia care practice. Methods: An exploratory and descriptive design was used in Study I. An exploratory and interpreting design was used in Study II and Study III. A prospective, descriptive, observational and instrumental design was used in Study IV. Focus group interviews (I) and individual interviews (II, III) were applied to explore and describe RNs’ and CNAs’ experiences of pain assessment in people living with dementia. Qualitative content analysis (I) and philosophical hermeneutics (II) were used to analyse qualitative data. Observation, instrument, and questionnaire were applied to evaluate reliability and face validity of the APS-SWE for pain assessment. Descriptive statistics and reliability analyses were used to analyse quantitative data (IV). Results: RNs in special housing accommodation settings experiences that pain assessment in people with dementia is challenging primarily due to their changed RN consultant role, which to a great extent is directed into administrative and consultative tasks rather than bedside care. This has led to decreased time in daily nursing care, preventing recognising symptoms of pain. This have also led to that RNs are dependent on information from CNAs who are the front-line staff providing daily care (I). CNAs’ perception of signs of pain in people with dementia emerges from being present in the care situation and alertness on physical and behavioural changes that could be due to pain, and from providing the care in a preventive, protective and supportive way to prevent painful situations occurring (II). RNs and CNAs working in home healthcare team use a variety of strategies to detect and assess pain. A trustful work relationship based on staff continuity and a good relation to the person in need of care facilitates pain assessment situations (III). Systematic observation of older people living in special housing accommodation during rest and mobility using the APS-SWE demonstrates that the scale has adequate internal consistency, reliability, and face validity for pain assessment (IV). Conclusions: This thesis found that the RNs’ and CNAs’ detections and assessments of pain rely on solid cooperation, staff continuity, and good knowledge of the person cared for. It was also revealed that there is a lack of using appropriate and assisting pain tools. The APS-SWE show adequate reliability and face validity and can serve as a useful pain tool to assist in detection and assessment of pain in older people who are limited in verbalising pain recognisable. Further evaluation of how the person-centred perspective is applied in pain assessment situations is needed in order to evaluate positive outcomes in people with dementia. Further psychometric evaluation of the APS-SWE in clinical dementia care practice is needed to strengthen validity and reliability. / <p>Study IV</p><p>Karlsson C, Ernsth Bravell M, Ek K, Johansson L &amp; Bergh I (2014): Reliability and face validity of the Abbey Pain Scale-SWE in Swedish dementia care practice. Submitted June, 2015.</p>