Bakgrund: Hemsjukvård är en växande och skiftande vårdform i Europa. De närståendes omvårdnadsinsatser är ofta avgörande för en fungerande hemsjukvård. Närståendevård kan samtidigt medföra risker för de närståendes hälsa. Styrdokument för hälso- och sjukvården betonar vikten av patientens och de närståendes delaktighet i vårdens utformning och utförande. Hemmet utgör en speciell vårdkontext, som visats påverka vårdpersonalens och patienternas upplevelser - troligen också de närståendes. Syfte: Att, i en europeisk kontext, beskriva de närståendes upplevelser av delaktighet i hemsjukvård. Metod: Litteraturöversikt av kvalitativa vetenskapsartiklar. Tre elektroniska databaser genomsöktes och elva studier, utgivna mellan 2013 och 2018, inkluderades. Genom kvalitativ dataanalys identifierades teman som präglade de närståendes upplevelser av delaktighet med hemsjukvården. Resultat: Analysen fann tre teman: de närstående utför omvårdnadsprocesser, de närstående griper efter hemsjukvården, samt vårdarnas makt över hopp och förtvivlan. Diskussion: Resultaten diskuterades utifrån Andersheds och Ternestedts teori om närståendes delaktighet. Studier om hopp och fasta vårdkontakter satte resultaten i kontext. De närståendes upplevda ansvar och resurser diskuterades som förutsättningar för delaktighet. / Background: Home health care comprises an increasing and diverse range of services throughout Europe. In order to work, these services often rely on care performed by informal caregivers. Informal care can entail risks to the relatives’ health. Legal and policy documents stress the importance of patients’ and relatives’ participation in health care decisions and delivery. The home as a care context has been found to influence the patients’ and health professionals’ experiences, and should be studied also from the relatives’ perspective. Aim: To describe informal caregivers’ experiences of participation in home health care, in a European context. Method: Review of qualitative literature. Three electronic databases were searched, and eleven studies, published between 2013 and 2018, were identified for inclusion. Through qualitative content analysis, themes that defined the informal caregivers’ experiences of participation were identified. Results: Three themes were formulated: relatives perform care processes, relatives grasp at the home health care service, and care professionals mediate hope and despair. Discussion: The results were discussed in relation to Andershed’s and Ternestedt’s theory of relatives’ involvement. Studies of hope and case management contextualized the findings. The informal caregivers’ perceived responsibility and resources were discussed as conditions of participation.

Dans le cadre des contraintes économiques et des évolutions démographiques auxquelles doit faire face le secteur de la santé, l’Hospitalisation à Domicile (HAD) qui a été créée il y a une soixantaine d’années s’est largement développée en France durant cette dernière décennie. L’objectif principal de cette alternative à l’hospitalisation complète est de raccourcir les séjours hospitaliers voire même de les éviter en vue de remédier à l’engorgement des hôpitaux tout en améliorant les conditions de vie des patients. Dans cette thèse, nous nous intéressons à la gestion des opérations dans les structures d’HAD. Dans la première partie, nous développons une analyse qualitative de la gestion des opérations dans les établissements d’HAD. De façon plus détaillée, nous identifions les différents facteurs de complexité auxquels la gestion des opérations doit faire face dans ce type de structures. Ces facteurs peuvent concerner la diversité de l’offre des services, le lieu de production des soins, les sources d’incertitudes, etc. Nous présentons ensuite les travaux existants dans la littérature qui s’intéressent à la gestion des opérations dans les HADs. Sur la base de cette synthèse, nous identifions des pistes de recherche qui n’ont pas encore été traitées dans la littérature. Dans la deuxième partie, nous nous intéressons à la problématique de partitionnement géographique du territoire desservi par une structure d’HAD. Cette approche de partitionnement peut s’insérer dans une politique d’amélioration de la qualité du service des soins délivrés aux patients et des conditions de travail des équipes soignantes. Nous commençons d’abord par proposer une classification des différents critères utilisés dans la littérature pour modéliser ce problème. Nous proposons ensuite deux modèles de partitionnement prenant en compte un ensemble de critères tels que l’équilibre de la charge de travail, la compacité, la compatibilité et l’indivisibilité des unités de base. Nous présentons également quelques exploitations possibles de ces modèles et proposons deux extensions à la formulation de base. Après avoir formulé le problème avec une approche statique, nous développons également une extension dynamique qui permet d’intégrer les différentes variations pouvant être observées dans l’activité d’une HAD d’une période à l’autre. Nous introduisons un nouveau critère de partitionnement qui concerne la continuité des soins, évaluée sur la base de deux sous-critères. En fonction des préférences des décideurs par rapport à la prise en compte de la continuité des soins dans le problème de partitionnement, nous distinguons alors trois scénarii pour lesquels nous proposons les modèles associés / Within the framework of economic constraints and demographic changes which the health care sector is confronted to, the Home Health Care (HHC) which has been created sixty years ago, has known an important growth during this last decade. The main objective of this alternative to the traditional hospitalization consists in solving the problem of hospitals’ capacity saturation by allowing earlier discharge of patients from hospital or by avoiding their admission while improving or maintaining the medical, psychological and social welfare of these patients. In this thesis, we are interested in the operations management within the HHC structures. In the first part of this thesis, we develop a qualitative analysis of the operations management in the HHC context. More specifically, we identify the complexity factors that operations management has to face up within this type of structures. For each complexity factor, we discuss how it can affect the organization of the care delivery. These factors pertain to the diversity of the services proposed, the location of care delivery, the uncertainty sources, etc. Thereafter, we survey operations management based models proposed in the literature within the HHC context. Based on this literature review, we identify several emerging issues, relevant from an organizational point of view, that have not been studied in the literature and thus represent unexplored opportunities for operations management researchers. In the second part of this thesis, we are interested in the partitioning of the area where the HCC structure operates into districts. This districting approach fits the policies of improvement of the quality of care delivered to patients and the working conditions of care givers as well as costs’ reduction. We begin by proposing a classification of the different criteria that may be considered in the districting problem. We then propose two mathematical formulations for the HHC districting problem for which we consider criteria such as the workload balance, compactness, compatibility and indivisibility of basic units. After that, we present a numerical analysis of the computational experiments carried out on randomly generated instances to validate these two models. We also present two possible exploitations of these models and propose two extensions to these basic formulations. After formulating the problem with a static approach, we also develop a dynamic extension which allows the integration of the different variations that can be observed within the activities of an HHC structure from period to period. We then introduce a new partitioning criterion that concerns the continuity of care evaluated on the basis of two sub-criteria. Depending on the preferences of the decision-makers concerning the sub-criteria related to the continuity of care in the districting problem, we then distinguish three scenarios for which we propose the associated mathematical formulations.

L'affectation des patients aux soignants et le séquencement des visites à effectuer par les soignants sont deux problématiques intéressantes observées dans les établissements de soins décentralisés tels que les établissements d'HAD (Hospitalisation à Domicile), de SSIAD (Soins et services infirmiers à Domicile) ou de MAD (Maintien à Domicile). Le premier problème consiste en effet à décider quels soignants fourniront quels services (visites) à quels patients, tandis que le second vise à déterminer la séquence de visites de chaque soignant. Du point de vue de la modélisation, ces deux problèmes peuvent être résolus par une approche séquentielle qui comprend deux étapes ou une approche simultanée. Bien que les résultats de l'approche simultanée soient plus précis en raison de la résolution des problèmes d'affectation et de routage en même temps, son application semble être peu adaptée à des situations réelles, souvent de grande échelle. Dans cette thèse, nous nous concentrons sur l'approche en deux étapes qui considère successivement le problème d'affectation (assignment) et de séquencement (routing) afin de comparer ses performances à celles obtenues par l'approche simultanée. Ainsi, plusieurs variantes de modèles mathématiques sont développées en tenant compte de : (1) la compatibilité de compétences entre les patients et les opérateurs, (2) périodes de planification uniques ou multiples, (3) contraintes au niveau des capacités disponibles des soignants. Le verrou scientifique au niveau de l'approche en deux étapes concerne essentiellement l'estimation de la durée des déplacements des soignants, estimations qui sont nécessaires pour résoudre le problème d'affectation. A cette fin, nous proposons une méthode utilisant des données empiriques basée sur la technique de régression de Kernel (Kernel Regression Technique) permettant d'estimer les durées de déplacement. Cette méthode utilise des données historiques sur les durées de déplacement qui intègrent plusieurs facteurs réalistes concernant les conditions cliniques des patients et les conditions géographiques, ou encore les préférences personnelles des soignants afin d'estimer la durée nécessaire pour visiter un ensemble de patients situés dans la zone de service donnée. Des études numériques basées sur des données réelles en provenance d'un établissement d'HAD italien sont réalisées pour analyser les performances de la méthode d'estimation proposée. Les résultats obtenus montrent que cette nouvelle méthode d'estimation ainsi que l'approche en deux étapes sont des approches prometteuses pour traiter des problématiques de planification de ressources humaines dans les établissements d' HAD, SSIAD ou MAD. / The care givers' assignment and routing problems are relevant issues for Home Health Care (HHC) service providers. The first problem consists of deciding which care givers will provide services to which patients, whereas the second aims at determining the visiting sequences of care givers. From a modelling perspective, these problems can be solved with either a two-stage approach or a simultaneous approach. Although the currently most known simultaneous approach yields more accurate results by solving the assignment and routing problems at the same time, its resolution remains computationally difficult and not viable for large scale applications. In this thesis, we focus on the two-stage approach that sequentially solves an assignment and a routing problem in order to compare its performances to those of the simultaneous approach. Hence, several variants of mathematical models are developed by taking into account: (1) the skill compatibilities between patients and operators; (2) single or multiple planning periods; (3) imposed or released operator capacity restrictions. An important point regarding the two stage approach concerns the estimation of care givers' travel times that are required to solve the assignment problem. For this purpose, we propose an empirical data-driven method that is based on the Kernel Regression technique to estimate travel times. Such a method uses care givers' historical travel times that integrate several realistic factors such as cared patients' clinical conditions and locations or care givers' personal preferences to estimate the time necessary for visiting a set of patients located in the HHC service area. Numerical studies based on realistic problem instances are used to analyze the performances of the proposed data-driven travel time estimation method and the two-stage approach. Results obtained show that both the newly developed travel time estimation method and the two-stage models are promising approaches for the HHC human resource planning process.

Introdução: define-se rede social como o grupo com quem a pessoa mantém algum vínculo social; já o apoio social refere-se ao grau de satisfação do indivíduo com suas relações, podendo ser agrupado em cinco dimensões: material, afetiva, emocional, de informação e interação positiva. Cuidar de um familiar dependente pode ocasionar várias mudanças na vida do cuidador, o que o leva a depender ainda mais do apoio de sua rede social. Objetivo: avaliar a rede e o apoio social de cuidadores familiares de pacientes dependentes atendidos por um Serviço de Assistência Domiciliária. Método: estudo descritivo, transversal, realizado em um Serviço de Assistência Domiciliária localizado na zona sul do município de São Paulo. A amostra foi constituída por 110 cuidadores familiares que realizavam a atividade há mais de três meses e que não recebiam remuneração pelo cuidado prestado. As entrevistas foram realizadas no período de março a novembro de 2011 e foram utilizados os seguintes instrumentos: formulário de caracterização sociodemográfica, Social Network Index, Medical Outcomes Study, Índice de Barthel e Genograma. A análise descritiva foi realizada através de cálculo de medida de tendência central e de dispersão e cálculo de frequências. Foi realizado teste U de Mann-Whitney, Kruskal-Wallis e correlação de Spearman. Foi adotado nível de significância de 5%. Todos os procedimentos éticos foram seguidos. Resultados: a maior parte dos pacientes era do sexo feminino, com idade média de 67 anos e totalmente dependente para atividades da vida diária. Os cuidadores eram, em sua maioria, do sexo feminino, com idade média de 52 anos, casadas e eram filhas do paciente. A rede social era composta principalmente pelos familiares, com média de quatro pessoas. O escore médio de apoio social total foi de 77,5. Cuidadores que não sabiam ler e que nunca haviam estudado apresentaram diferença estatisticamente significativa entre as médias na dimensão material, emocional, de interação positiva e de informação. Verificou-se diferença entre as médias na dimensão afetiva para a variável presença de dor; na dimensão interação positiva também se observou diferença entre o escore médio na variável presença de companheiro e a presença de sobrecarga. A dimensão material apresentou correlação estatisticamente significativa com a variável idade e o número de familiares e amigos apresentou correlação com todas as dimensões de apoio social. Conclusão: a avaliação da rede e do apoio social de cuidadores familiares pode auxiliar os profissionais de saúde no planejamento da assistência e contribuir para amenizar o impacto do cuidado ao familiar que exerce essa função. / Introduction: social network is defined as the group with whom the person has a social bond, whilst social support refers to the level of satisfaction of the individuals with their relationships and can be grouped into five dimensions: material, affective, emotional, informational and positive interaction. Caring for a dependent relative can cause several changes in the caregivers life, which make them to depend even more on the support of their social network. Objective: to evaluate the social network and the support of family caregivers of dependent patients attended by a Home Care Service. Method: descriptive, cross-sectional study, conducted in a Home Care Service located in the south of Sao Paulo city. The sample consisted of 110 family caregivers, who performed the activity for more than three months and did not receive payment for the care provided. The interviews were conducted from March to November 2011 and the following instruments were used: questionnaire of socio-demographic characteristics, Social Network Index, Medical Outcomes Study, Barthel Index and Genogram. A descriptive analysis was realized by calculating a measure of central tendency and dispersion and frequency calculation. The Mann-Whitney test U, Kruskal-Wallis and Spearman correlation were used. The significance level adopted was 5%. All ethical procedures were followed. Results: Most patients were female, with mean age of 67 years and totally dependent for activities of daily living. Caregivers were mostly female, with an average age of 52 years, married and daughters of the patient. The social network was composed mostly by family members, with an average of four persons. The average of the total social support was 77,5. Caregivers who could not read and who had no formal schooling showed statistically significant differences between the means presented in the material, emotional, positive interaction and information dimensions. There was a difference between the means in the affective dimension and the variable presence of pain; there was a difference in the dimension positive interaction between the mean score in the variable presence of companion and overload. The material dimension showed significant correlation with the variable age, and number of family and friends correlated with all dimensions of social support. Conclusion: The evaluation of social network and support of family caregivers can help health professionals in care planning and to mitigate the impact on the caregiver.

Bakgrund: Hemsjukvård är en vårdform som ökar och även fortsättningsvis förväntas göra så. Patientsäker är en nationell och internationell prioritet där läkemedelshantering är ett riskområde såväl inom hemsjukvård som slutenvård. Tidigare forskning har i högre utsträckning fokuserat på patientsäkerhet inom slutenvården och att belysa patientsäkerhet inom hemsjukvård och vad sjuksköterskor kan göra för ökad patientsäkerhet är därför av vikt. Syfte: Att undersöka patientsäkerhetsrisker avseende läkemedelshantering inom hemsjukvården samt vad sjuksköterskor kan göra för att öka patientsäkerheten inom området. Metod: Studien har genomförts som en litteraturöversikt och resultatet baseras på 14 vetenskapliga artiklar. Litteratursökning har utförts i databaserna Cinahl och PubMed och innehållsanalys användes för artiklarnas resultat. Resultat: Nio patientsäkerhetsrisker identifierades där brist på kompetens, brister i kommunikation, delegeringsprocessen, komplexa sjukdomstillstånd och informationsöverföring är några av dessa. De identifierade riskerna delades vidare in i tre olika huvudområden beroende på bakomliggande orsak: Sjuksköterskor och annan vårdpersonal; Patient och hemmiljön; Organisation och system. Konklusion: Läkemedelshantering är ett betydande riskområde inom hemsjukvården där många faktorer påverkar patientsäkerheten. Att sjuksköterskor och annan personal inom hemsjukvården är väl medvetna om dessa risker ger en bra förutsättning för att kunna arbeta preventivt och minimera att vårdskador relaterat till läkemedelshantering uppstår. / Background: The number of patients receiving medical care in their own home is increasing. Home health care is a trend that is expected to continue. Patient safety is a national and international priority, where medical management is a risk area both in home and institutional care. Previous research has focused more on patient safety in institutional care. Highlighting patient safety and what nurses can do to increase patient safety in home care is therefore important. Aim: The aim of this study was to explore patient safety risks regarding medical management in home health care and what nurses can do to increase patient safety in the area. Method: This study was conducted as a literature review and the result is based on 14 scientific articles. The searches were performed in the databases Cinahl and PubMed. Result: Nine patient safety risks were identified where lack of competence, shortcomings in communication, the delegation process, comorbidity and information transfer are some of them. The identified risks were further linked to three main areas depending on the underlying cause: Nurses and other health professionals; Patient and the home environment; Organisation and systems. Conclusion: Medical management is a significant risk area in home health care where many factors affect patient safety. That nurses and other home care professionals are well aware of these risks provide a good prerequisite for preventing and minimizing the incidence of medical related adverse events.

This study aimed to describe and analyze experiences of chronic patients family carers in home stay, as well as to discuss the importance of such experiences to nursing care. It is a qualitative research developed in the Service of Home Health Care of Santa Maria s University Hospital (SIDHUSM), to which contributed 15 chronic patients family carers. This study made use of creative and sensitive method (MCS) by Cabral (1998) and the dynamics of creativity and sensitivity: Life Line, Body-Knowledge and Almanac. Data were analyzed by using some of the theoretical concepts of Discourse Analysis by Orlandi (2002). Thus, it was possible to structure two analytical categories: the first is related to the experience of being a family carer in the context of home care, which was developed in the themes: the care as an experience inherent to human beings; the experience of taking care in a disease situation; the learning with the experience of being a carer; the implications in the experience of being a carer and the home health care as a support in the care of patients in their homes. The second category is about the strategies used by carers in the care of their familiars, which was developed in the themes: the expressivity in the care; the concern with the environment and the importance of the social net support. The results pointed to the necessity of valuing the care activities developed by home carers and the built of a formal and informal net of support and help to family carers. In regard to the formal net of support, one highlighted the home care as a modality of humanizing and innovating attention which aims to invert health professionals logic of action. The moment that health professional group goes to patient s home, a space to a relation of trust and mutual help is opened allowing the construction of new knowledge. / Este estudo teve como objetivo descrever e analisar as experiências dos cuidadores familiares de doentes crônicos em internação domiciliar, bem como discutir a importância dessas experiências para o cuidado de enfermagem. Trata-se de uma pesquisa do tipo qualitativa, desenvolvida no Serviço de Internação Domiciliar do Hospital Universitário de Santa Maria (SIDHUSM), os quais participaram 15 cuidadores familiares de doentes crônicos. Para a produção dos dados utilizou-se o método criativo e sensível (MCS), teorizado por Cabral (1998), e as dinâmicas de criatividade e sensibilidade: Linha da Vida, Corpo-Saber e Almanaque. Os dados foram analisados utilizando-se alguns pressupostos conceituais da análise de discurso de Orlandi (2002). Dessa forma foi possível estruturar duas categorias analíticas: a primeira se relaciona a experiência de ser cuidador familiar no contexto da internação domiciliar, desdobrados nos temas: o cuidado como uma experiência inerente ao ser humano; a experiência de cuidado na situação de doença; o aprendizado com a experiência de ser cuidador; implicações na experiência de ser cuidador e a internação domiciliar como um suporte no cuidado ao doente no domicílio. A segunda categoria discorre sobre as estratégias utilizadas pelos cuidadores no cuidado do seu familiar, desdobrada nos temas: a expressividade no cuidado; a preocupação com o ambiente e a importância da rede de apoio social. Os resultados apontaram para a necessidade da valorização das atividades de cuidado realizadas pelos cuidadores no domicílio e da construção de uma rede formal e informal de suporte e ajuda aos cuidadores familiares. Em relação à rede formal de suporte destacou-se a internação domiciliar como uma modalidade de atenção humanizadora e inovadora que visa inverter a lógica de atuação dos profissionais de saúde. No momento em que a equipe de saúde se desloca até o domicílio do doente abre-se espaço para uma relação de confiança e ajuda mútua possibilitando a construção de novos saberes.

Background: Palliative care is based on a holistic approach to maintain quality of life and alleviate suffering. The increased life expectancy where more people are living with chronic diseases means that the need for palliative care is increasing. Palliative home care is conducted through a team-based approach where the person and the relative are seen as a part of the care team. The nurses primary work is caring which includes giving support and alleviating suffering. The work also includes administrative tasks such as documentation and coordination. More knowledge about nurses experiences of working with palliative home care is required to increase understanding. Aim: Describe nurses experiences of providing palliative homecare. Method: Literature review with a thematic analysis including 10 articles. Results: Four themes were identified, collaboration between the professions, emotional challenges, time consuming work and cooperation with relatives. Conclusion: Palliative home care yields nurses many advantages in their caring role but requires competence and well-structured organisations. Nurses must advocate for all parties involved, including themself to be able to provide quality care. Present study identifies that nurses finds themself emotionally engaged in their work which is both an asset and a vulnerability. / Bakgrund: Den palliativa vården utgår från en helhetssyn på människan för att bibehålla livskvalité och lindra lidande. Den ökade medellivslängden där allt fler lever med kroniska sjukdomar medför att behovet av palliativ vård ökar. Den palliativa hemsjukvården bedrivs genom ett teambaserat tillvägagångssätt där personen och anhöriga ses som en del av vårdteamet. Sjuksköterskans primära arbete är omvårdnad vilket innefattar stöd och lindra lidande. Arbetet inkluderar även administrativa uppgifter såsom dokumentation och koordination. Det krävs mer kunskap om sjuksköterskors upplevelse av att arbete med palliativ vård i hemmet för att öka förståelsen. Syfte: Var att beskriva sjuksköterskors erfarenhet av palliativ vård i hemmet. Metod: Litteraturöversikt med tematisk analys inkluderande 10 artiklar. Resultat: Fyra teman identifierades, samarbete mellan professionerna, emotionella utmaningar, tidskrävande arbete och samverkan med anhöriga. Slutsatser: Palliativ vård i hemmet ger sjuksköterskor många fördelar i sitt utövande men ställer krav på kompetens och välstrukturerade organisationer. Sjuksköterskor behöver representera och advocera för alla parter, inklusive sig själv för att tillgodose god vård. I föreliggande studie framkommer att sjuksköterskor finner sig själva emotionellt engagerade iarbetet vilket är både en tillgång och en utsatthet.

Sammanfattning   Titel: Sjuksköterskors erfarenheter av palliativ vård i hemmet.    Bakgrund: Palliativ vård handlar om att lindra ett lidande, främja patientens livskvalitet samt att beakta patientens behov vid ett obotligt sjukdomstillstånd. Många patienter som vårdas inom palliativ vård önskar att få somna in i sitt eget hem. Sjuksköterskan behöver då ha kunskap, kompetens och erfarenhet för att vårda patienten på bästa sätt.    Syfte: Att beskriva sjuksköterskors erfarenheter av att vårda vuxna patienter som erhåller palliativ vård i hemmet.   Metod: En kvalitativ litteraturöversikt som baserades på elva vårdvetenskapliga artiklar. Databaserna som användes var CINAHL och PsycINFO samt en manuell sökning. Analysen gjordes enligt Fribergs analysstruktur. Från analysen framträdde två huvudteman och sex subteman.   Resultat: Resultatet presenteras i två huvudteman: Att samarbeta i team, Att möta utmaningar vid palliativ vård i hemmet. Vidare presenterades sex subteman: Att samarbeta interprofessionellt, Att samarbeta med patienter, Att samarbeta med närstående, Att anpassa vården i hemmiljön och att känna osäkerhet, Att uppleva att personcentrerad vård inte prioriteras.   Slutsats: God kommunikation och samarbete underlättar en säker och personcentrerad vård. Sjuksköterskans arbetsmiljö brister på flera plan, vilket ger risk för skador och stressrelaterade symtom. Hierarkin påverkar vården negativt och leder i många fall till avsaknad av personcentrering.   Nyckelord: Hemsjukvård, Palliativ vård, Sjuksköterskor, erfarenhet. / Summary   Titel: Nurses´experiences of palliative care in home health care.     Background: Palliative care is about alleviating suffering, promoting the patient's quality of life, and considering the patient's needs in the event of an incurable disease. Many patients who are cared for in palliative care wish to die in their own home. The nurse needs to have knowledge, competence, and experience to care for the patient in the best way possible.   Aim: To describe nurses experiences of caring for adult patients who are receiving palliative care in their home.   Method:  A qualitative literature review based on eleven nursing scientific articles. The databases used were CINAHL, PsycINFO and a manual search. The analysis was performed according to Friberg's analysis structure. From the analysis, two main themes and six sub-themes emerged.   Results: The results were presented in two main themes: Collaborating in teams and Meeting challenges in palliative care at home. Furthermore, six sub-themes were presented: Collaborating interprofessionally, collaborating with patients, collaborating with relatives, Adapting care in the home environment, Feeling insecure and To experience that person-centered care is not a priority   Conclusion: Good communication and cooperation facilitates safe and person-centered care. The nurse's work environment is inadequate on several levels, which gives rise to the risk of injuries and stress-related symptoms. The hierarchy has a negative effect on care and in many cases leads to a lack of person-centered care.   Keywords: Home health care, Nurses’ experience, palliative care

Background: Pressure ulcers are a problem that can lead to psychological, economical and physical issues for patients in a community. Pressure ulcers can occur in different settings and home healthcare is one of them. Pressure ulcers can emerge fast on pressure exposed areas of the body and can take a long time to heal. The registered nurses’s nursing work includes preventing and treating pressure ulcers. Aim: The aim of the study was to describe registered nurses preventive nursing care for pressure ulcers in home health care. Method: A literature review with 10 original articles which was analysed with a manifest content analysis. Result: The analysis resulted in twomain categories and five subcategories. One of the main categories was Nursing based on the profession as an expert with educating the team and team cooperation as subcategories. The other main categories was Nursing with an evidence based practice with skin assessment, risk assessment, repositioning and pressure reliving devices as subcategories. Conclusion: To prevent pressure ulcers in patients in home healthcare registered nurses must work with an academic basis where the team gets educated and cooperated. They should also work with an evidenced based practice where skin assessment, risk assessment, repositioning and pressure reliving devices are used. / Bakgrund: Trycksår är ett problem som kan leda till en psykisk, ekonomisk och fysisk skada för patienter i samhället. Trycksår kan uppstå i olika sammanhang där hemsjukvård är en av dem. Trycksår kan uppstå fort på tryckutsatta kroppsdelar och kan ta lång tid att behandla. I sjuksköterskans omvårdnadsarbete ingår det att förebygga och behandla trycksår. Syfte: Syftet med studien var att beskriva hur sjuksköterskors omvårdnadsarbete kan förebygga trycksår. Metod: En litteraturöversikt med 10 originalartiklar och data analyserades med en manifest innehållsanalys. Resultat: Analysen resulterade i två huvudkategorier samt fem subkategorier. Huvudkategori var omvårdnad utifrån professionen som expert med subkategorierna utbilda teamet och samverka i team samt omvårdnad utifrån evidens med subkategorier hudbedömning, riskbedömning och lägesändring och tryckavlastande hjälpmedel. Slutsats: För att förebygga trycksår hos patienter inom hemsjukvården bör sjuksköterskor arbeta med omvårdnad utifrån professionen som expert där teamet utbildas och samverkar. Det bör även arbeta utifrån evidensbaserade åtgärder med hjälp av hudbedömningar, riskbedömningar och lägesändringar samt tryckavlastande hjälpmedel.

SAMMANFATTNING Titel: Distriktssköterskans upplevelser av palliativ vård i hemsjukvården Fakultet: Fakulteten för hälsa, natur- och teknikvetenskap Kurs: Examensarbete - omvårdnad, 15hp Författare: Helena Dellgren & Louise Olsson-Öhrn Handledare: Ingela Leibring Examinerande lärare: Brian Unis Examinator: Karin Josefsson Sidor: 27 s., exklusive bilagor Datum för examination: 2022-01-12 Svenska nyckelord: sjuksköterska, upplevelse, palliativ vård, hemsjukvård Introduktion: Palliativ vård i hemsjukvården är en vårdform som allt fler människor väljer. Den ska innefatta ett gott omhändertagande samt professionella bedömningar utifrån patientens fysiska, sociala, psykiska samt existentiella behov. Palliativ vård är en komplext vårdform vilket ställer höga krav på professionen. Syfte: Var att belysa distriktssköterskans upplevelse av palliativ vård i hemsjukvården. Metod: En systematisk litteraturstudie som utgick ifrån Polit & Becks niostegsmodell. Kvalitativ innehållsanalys med kondenserat material enligt Graneheim & Lundman utifrån tio vetenskapliga artiklar framsökta i databaserna Cinahl och Psykinfo. Resultat: Det sammanställda resultatet presenterades i tre kategorier: Upplevda känslor, betydelsen av personliga egenskaper, upplevelser av organisationens betydelse med följande sex underkategorier: medkänslans betydelse, att vara lyhörd och närvarande, behovet av stöd och reflektion, samarbete är en förutsättning, kompetens har betydelse, tiden är avgörande. Konklusion: Tiden är en avgörande faktor och förmågan att känna medkänsla och lyhördhet är en förutsättning vid palliativ vård. Distriktssköterskan ställs ofta inför svåra möten och situationer i sin yrkesroll som kan vara svåra att hantera. Distriktssköterskan upplever bristande kompetens och framhäver behovet av mer utbildning inom palliativ vård / ABSTRACT Title: The district nurse's experiences of palliative care in home health care Faculty: Health, Science and Technology Course: Degree project - nursing, 15 ECTS Authors: Helena Dellgren & Louise Olsson-Öhrn Supervisor: Ingela Leibring Examiner: Brian Unis Examiner: Karin Josefsson Pages: 27 s., exklusive bilagor Date for the examination: 2022-01-12 Key words: nurse, experience, palliative care, home health care Introduction: Palliative care in home health care is a form of care that people mostly choose. It must include good care and assessments that are professional and performed based on the patient's physical, social, mental and existential needs. Palliative care is a complex form of care that places high demands on the profession. Aim: Where to highlight the district nurse's experience of palliative care in home health care. Method: A systematic literature study based on Polit & Beck's nine-step model. Qualitative content analysis with condensed material according to Graneheim & Lundman based on ten scientific articles searched in databases Cinahl and Psycinfo. Result: The compiled results were presented in three categories: Perceived emotions, the importance of personal qualities, experiences of the organization´s importance with the following six subcategories: the importance of compassion, being sensitive and present, the need for support and reflection, cooperation is a prerequisite, competence matters, time is crucial. Conclusion: Time is a decisive factor and the ability to feel compassion and sensitivity is a prerequisite for palliative care. The district nurse are often faced with difficult encounters and situations in their professional role that can be difficult to handle. The district nurse experience a lack of competence and emphasize the need for more education in palliative care