Bakgrund: I sjuksköterskans yrkesprofession ingår palliativ vård som syftar till att ge patienter i livets slutskede bästa möjliga livskvalitet och symtomlindring. Alla patienter har varierande behov vilket gör att omvårdnaden behöver personcentreras. Syftet: Syftet var att undersöka sjuksköterskors erfarenheter av att vårda patienter palliativt i hemsjukvård. Metod: Studiens metod var en litteraturbaserad studie baserad på elva kvalitativa artiklar. Resultat: Sjuksköterskorna ansåg att etablera en god vårdrelation tidigt i palliativ vård ökade möjligheterna att ge en personcentrerad omvårdnad, där individens behov och önskemål togs i beaktskap. Däremot kunde detta bemötas med utmaningar som kunde grunda sig i olika etiska dilemman. Dessutom upplevdes yrket vara känslomässigt utmanande där sjuksköterskorna dagligen försökte balansera sin professionella roll, personliga känslor och etiska dilemman. Vidare upplevde sjuksköterskorna komplexitet av att patienternas hem omvandlades till deras nya arbetsmiljö samtidigt som en trygg och lugn miljö var avgörande vid vård i livets slutskede. Konklusion: Studiens resultat belyser vikten av kunskap och erfarenheter som en trygg grund inför arbetet med palliativ vård. Genom att sjuksköterskor besitter nödvändiga kunskaper kan detta överföras i omvårdnaden och göra patientens sista tid fridfull. Utökad kunskap om palliativ vård i grundutbildning är önskvärt samtidigt som verksamheterna behöver införa rutiner för reflektioner med kollegor, vilka tillsammans är av vikt för att bearbeta samt få mer erfarenhet. / Background: The nurse's profession includes palliative care, which aims to give patients at the end of life the best possible quality of life and symptom relief. All patients have varying needs, which means that care needs to be individually adapted. Purpose: The purpose was to investigate nurses' experiences of caring for palliative patients in home health care. Method: The study's method was a literature review based on eleven qualitative articles. Results: The nurses believed that establishing a good care relationship early in palliative care increased the possibilities of providing person-centred care, where the individual's needs and wishes were taken into account. However, this could be met with challenges that could be based on various ethical dilemmas. In addition, the profession was perceived to be emotionally challenging where the nurses daily tried to balance their professional role, personal feelings and deal with ethical dilemmas. Furthermore, the nurses experienced the complexity of the patients' homes being converted into their new work environment, while a safe and calm environment was crucial in end-of-life care. Conclusion: The study’s results clearly highlight the importance of knowledge and experience as a secure foundation for work in palliative care. Because the nurse possesses the necessary knowledge, this can be transferred in the care and make the patient calm. Expanded knowledge about palliative care in basic education is desirable at the same time as the operations need to introduce routines where reflections colleagues together are important to process and gain more experiences.

Introdução: A atenção domiciliar (AD) vem ganhando destaque em função do envelhecimento da população e do predomínio das doenças e agravos não transmissíveis, como uma alternativa aos modos já instituídos de cuidado, podendo ser uma modelagem potente que permite a transformação das práticas de saúde, produzindo uma assistência que favorece a criação de vínculo entre trabalhador e usuário, o acolhimento, a humanização e o desenvolvimento de corresponsabilidade. Em 2011, foi criada a política nacional de atenção domiciliar, regulamentada pela Portaria no 963/GM/MS de 27 maio de 2013, a qual estabelece diretrizes bastante específicas acerca dos serviços de AD e institui o cofinanciamento federal, o que poderá implicar numa ampliação significativa dos serviços existentes. Objetivo: Analisar experiências de atenção domiciliar do SUS, suas potencialidades e desafios na produção do cuidado, bem como os efeitos iniciais da Portaria nº 963/GM/MS, de 27 de maio de 2013 sobre as iniciativas municipais. Métodos: Pesquisa qualitativa de abordagem cartográfica, onde foram explorados três serviços de AD do SUS, no Estado de São Paulo. Com o intuito de mapear analisadores significativos para a potencialização da atenção domiciliar como arranjo assistencial para produção do cuidado orientada à integralidade, diferentes iniciativas compuseram a cartografia, tais como entrevistas, observação participante e construção de diário de campo. Resultados e Discussão: A AD pode ser um importante dispositivo para análise das tensões, apostas e desafios que emergem na prática dos serviços de saúde, bem como dar a visibilidade aos vazios assistenciais na rede. A portaria ministerial quando tomada como dispositivo, faz normatizações que vem gerando tensões junto aos SAD, ao mesmo tempo em que estes criam linhas de fuga ao produzirem outros arranjos. Conclusão: A AD pode ser uma modelagem substitutiva ao modelo hospitalocêntrico, ao mesmo tempo que pode ser uma estratégia ao enfrentamento de dificuldades que a atenção básica sofre, o que pode orientar a construção de arranjos mais permeáveis à realidade brasileira. A AD pode ser um dispositivo fundamental para dar visibilidade aos vazios de atenção e para aprofundar a discussão sobre a rede e dispositivos de gestão do cuidado. / Introduction: Home care (HC) is gaining prominence due to the aging population and the prevalence of non-communicable diseases and injuries, as an alternative to established modes of care, being regarded as a powerful modeling organization that enables the transformation of health care practice, producing a company committed to creating relationship between worker and patient with hosting, humanization care and the development of responsibility. In 2011, the national policy of home care, regulated by Ordinance 963/GM/MS of May 27, 2013, which sets very specific guidelines about HC services and establishes the federal co-financing, which may involve a significant expansion of the services. Objective: To analyze home care experiences of the NHS, its potentials and challenges in care production, as well as the initial effects of Ordinance No. 963/GM/MS of 27 May 2013 on municipal initiatives. Methods: A qualitative study of cartographic approach, where three services of HC, located in the State of São Paulo, were explored. In order to map to significant analyzers to potentiation of home care as a medical care arrangement for care production oriented to the integrality, various initiatives were included in the mapping, such as interviews, participant observation and construction of a field diary. Results and Discussion: HC can be an important dispositive for analysis of tensions, bets and challenges emerging in the practice of health services, as well as giving visibility to the empty assistance in the health net. The ministerial order when taken as a dispositive, make regulations that has sparked tensions with the HC services, while they create other ways by producing other arrangements. Conclusion: HC may be a substitutive model of hospital-centered model, while it may be a strategy to cope with difficulties that primary care suffers, which can guide the construction of more permeable arrangements to Brazilian reality. HC can be a key device for providing visibility to empty the attention and further discuss about health network and managed care devices.

Cette thèse s’intéresse à trouver des solutions informatiques à certains problèmes de l’optimisation combinatoire, à savoir les problèmes de tournées de véhicules. Elle aborde les problèmes de Transport A la Demande (TAD). L’objectif principal visé dans cette thèse fait appel à certaines approches exactes et certaines approches méta-heuristiques pour résoudre des problèmes d’optimisation multi-objective de Transport A la Demande avec plusieurs véhicules. En effet, nos principaux objectifs de recherche consistent à : -I) Résoudre un problème multi-objectif de Transport A La Demande multi-véhicules basé sur la qualité de service ; - II) Résoudre un autre problème de Transport A la Demande multi-objectifs multi-véhicules. Ce problème traite un cas spécifique et qui consiste à l’application de ce problème aux domaines de l’Hospitalisation A Domicile (HAD). Nous avons appliqué des algorithmes exacts de "Branch and Bound" et des méthodes méta-heuristiques telles que l’algorithme évolutionnaire "Algorithme Génétique" et l’algorithme de "Colonie de Fourmis" pour apporter des solutions efficaces à ces différents problèmes. Un ensemble de résultats numériques est présenté pour chacune de ces méthodes pour montrer leurs capacités de produire des solutions de haute qualité en temps de calcul raisonnables. / This thesis focuses on finding computer science solutions for some combinatorial optimization problems, namely Vehicle Routing Problems (VRP). The thesis addresses the Dial A Ride Problems (DARP). Its main objective is to use some exact and meta-heuristics approaches to solve multi-objective optimization of Dial A Ride Problem with multi-vehicles. Hence, our main research aims are : - I)Solve a multi-objective Dial A Ride Problem with multi-vehicles based on quality of service, this problem treats a general case ; - II) Solve another multi-objective Dial A Ride Problem with multi-vehicles, this problem deals with a specific case which is an application of the Dial A Ride Problem in Home Health Care (HHC). We have also applied exact algorithms "Branch and Bound" and meta-heuristic algorithms such as evolutionary algorithms "Genetic Algorithm" and "Ant Colony" algorithm to provide effective solutions to these different problems. A set of numerical results are presented for each of these methods. Our results show that they produce high quality solutions in a reasonable execution time for all the treated problems.

Dans ce travail de recherche, l’intérêt est porté sur les établissements d’hospitalisation à domicile (HAD) avec l’objectif de développer une approche systématique et globale d’optimisation des soins à domicile dans le but de réduire les dépenses du domaine de la santé tout en satisfaisant une bonne qualité de service. Ce travail de recherche a pour objectif de proposer des modèles mathématiques, étudier les propriétés de ces modèles et développer des méthodes d’optimisation. La prise en compte des principales sources d’incertitudes dans la planification des soins à domicile est un objectif majeur de cette thèse. Dans ce travail, nous nous intéressons à trois problématiques distinctes issues du domaine d’HAD. La première concerne la planification multipériode des tournées des infirmiers en hospitalisation à domicile dont l’objectif consiste étudier le problème de la planification des soins à domicile sur plusieurs périodes en tenant compte de l’aspect de l’incertitude pour chaque période. Un plan hebdomadaire optimisé est donc établi afin de faciliter l’insertion des nouvelles demandes qui arrivent au cours de la semaine. Dans une deuxième problématique, nous étudions le problème de la planification des soins à domicile en tenant en compte de l’aspect de la pénibilité. Nous considérons ce concept comme résultant d’une situation de travail difficile et contraignante, pouvant causer un désintérêt, une situation de stress, voire une dégradation de l’état de santé du travailleur. La dernière problématique porte sur le problème de sectorisation qui impacte au niveau tactique la qualité de soin et de condition de travail pouvant être proposée. / The focus of this research is home health care activities planning. We aim to develop a global systematic approach in order to reduce costs of health care while satisfying a good quality of service. We propose mathematical modelsand we develop optimization methods. The major objective of this thesis is the consideration of the main sources of uncertainty in home health care planning. We are interested in three issues. The first is related to the multi-period home health care planning. An optimized weekly plan is established with a distribution of dle times that allows to insert new demands. We also study drudgery in the activities planning. We consider drudgery as constraining work, which can cause lack of interest or stress. The last topic concerns the districting problem as a key issue in an optimized home health care system organisation.

Introdução: A atenção domiciliar (AD) vem ganhando destaque em função do envelhecimento da população e do predomínio das doenças e agravos não transmissíveis, como uma alternativa aos modos já instituídos de cuidado, podendo ser uma modelagem potente que permite a transformação das práticas de saúde, produzindo uma assistência que favorece a criação de vínculo entre trabalhador e usuário, o acolhimento, a humanização e o desenvolvimento de corresponsabilidade. Em 2011, foi criada a política nacional de atenção domiciliar, regulamentada pela Portaria no 963/GM/MS de 27 maio de 2013, a qual estabelece diretrizes bastante específicas acerca dos serviços de AD e institui o cofinanciamento federal, o que poderá implicar numa ampliação significativa dos serviços existentes. Objetivo: Analisar experiências de atenção domiciliar do SUS, suas potencialidades e desafios na produção do cuidado, bem como os efeitos iniciais da Portaria nº 963/GM/MS, de 27 de maio de 2013 sobre as iniciativas municipais. Métodos: Pesquisa qualitativa de abordagem cartográfica, onde foram explorados três serviços de AD do SUS, no Estado de São Paulo. Com o intuito de mapear analisadores significativos para a potencialização da atenção domiciliar como arranjo assistencial para produção do cuidado orientada à integralidade, diferentes iniciativas compuseram a cartografia, tais como entrevistas, observação participante e construção de diário de campo. Resultados e Discussão: A AD pode ser um importante dispositivo para análise das tensões, apostas e desafios que emergem na prática dos serviços de saúde, bem como dar a visibilidade aos vazios assistenciais na rede. A portaria ministerial quando tomada como dispositivo, faz normatizações que vem gerando tensões junto aos SAD, ao mesmo tempo em que estes criam linhas de fuga ao produzirem outros arranjos. Conclusão: A AD pode ser uma modelagem substitutiva ao modelo hospitalocêntrico, ao mesmo tempo que pode ser uma estratégia ao enfrentamento de dificuldades que a atenção básica sofre, o que pode orientar a construção de arranjos mais permeáveis à realidade brasileira. A AD pode ser um dispositivo fundamental para dar visibilidade aos vazios de atenção e para aprofundar a discussão sobre a rede e dispositivos de gestão do cuidado. / Introduction: Home care (HC) is gaining prominence due to the aging population and the prevalence of non-communicable diseases and injuries, as an alternative to established modes of care, being regarded as a powerful modeling organization that enables the transformation of health care practice, producing a company committed to creating relationship between worker and patient with hosting, humanization care and the development of responsibility. In 2011, the national policy of home care, regulated by Ordinance 963/GM/MS of May 27, 2013, which sets very specific guidelines about HC services and establishes the federal co-financing, which may involve a significant expansion of the services. Objective: To analyze home care experiences of the NHS, its potentials and challenges in care production, as well as the initial effects of Ordinance No. 963/GM/MS of 27 May 2013 on municipal initiatives. Methods: A qualitative study of cartographic approach, where three services of HC, located in the State of São Paulo, were explored. In order to map to significant analyzers to potentiation of home care as a medical care arrangement for care production oriented to the integrality, various initiatives were included in the mapping, such as interviews, participant observation and construction of a field diary. Results and Discussion: HC can be an important dispositive for analysis of tensions, bets and challenges emerging in the practice of health services, as well as giving visibility to the empty assistance in the health net. The ministerial order when taken as a dispositive, make regulations that has sparked tensions with the HC services, while they create other ways by producing other arrangements. Conclusion: HC may be a substitutive model of hospital-centered model, while it may be a strategy to cope with difficulties that primary care suffers, which can guide the construction of more permeable arrangements to Brazilian reality. HC can be a key device for providing visibility to empty the attention and further discuss about health network and managed care devices.

Pressure injuries (PIs) affect an estimated 2.5 million people in America and cost the nation approximately $11.6 billion each year. The goal of this DNP project was to minimize the rate of PIs at a home health care agency through effective teamwork. Prevention of PIs is very important because PIs damage patients' skin integrity, cause significant amount of pain, are costly to treat, and cause life-threatening infections. The purpose of this DNP project was to evaluate nursing compliance with PI prevention measures and the level of nursing teamwork at the project agency. The Braden-Bergstrom conceptual framework was used to explain the etiology and progression of PI while Lewin's Change Theory was used to promote behavioral change in the nursing team. The practice-focused questions for closing the gap between nursing knowledge and practice were what percentage of nurses complied with standard PI prevention guidelines and what was the level of nursing staff teamwork in the agency per the Nursing Teamwork Survey [NTS]. This PI prevention initiative used a cross-sectional design. Data collection involved review of nursing documentation and electronic surveying of all nursing staff using the MISSCARE survey, the NTS, and the AHRQ assessment checklists, which were completed via SurveyMonkey, an online survey software. The impact of the PI prevention initiative was assessed by comparing the results of the documentation review and surveys pretest to the posttest results. There was significant improvement in nursing compliance with PI prevention and treatment. Pressure injury incidence rate fell from 13.6% to 5.1%. The positive social impact includes improving patient care and safety, minimizing PI incidence and producing an efficient team.

Les soins de santé à domicile (HHC) sont un large éventail de services de santé pouvant être dispensés à domicile pour une maladie ou une blessure. Ces dernières années, le secteur des soins de santé est devenu l'un des plus grands secteurs de l'économie des pays développés. L'un des défis les plus importants dans le domaine des HHC consiste à affecter plus efficacement les ressources en main-d'œuvre et les équipements sous des ressources limitées. Étant donné que le coût du transport est l’une des dépenses les plus critiques dans les activités de l’entreprise, il est très important d’optimiser le problème de routage des véhicules pour les sociétés HHC.Cependant, la majorité des travaux existants ne prennent en compte que le modèle déterministe. Dans la pratique de HHC, le décideur et les aidants rencontrent souvent des incertitudes. Il est donc essentiel d'intégrer l'incertitude dans le modèle pour établir un calendrier raisonnable pour la société HHC. Cette thèse aborde le problème du routage et de la planification HHC en prenant en compte respectivement la demande non déterministe, le service et le temps de parcours. Le corps principal de la thèse est composé de trois œuvres indépendantes.(1) Sur la base de la théorie de la crédibilité floue, nous avons proposé un modèle de programmation par contraintes de hasard flou (FCCP) pour le problème de routage HHC avec une demande floue. Ce modèle présente à la fois des caractéristiques d'optimisation combinatoire et de FCCP. Pour faire face au problème à grande échelle, nous avons développé un algorithme génétique hybride avec la simulation de Monte Carlo. Trois séries d'expériences ont été menées pour valider les performances du modèle et de l'algorithme proposés. Enfin, l’analyse de sensibilité a également porté sur l’observation du paramètre variable impliqué dans la prise de décision floue.(2) En fonction de l'activité des soignants de HHC, nous avons proposé un modèle de programmation stochastique en deux étapes avec recours (SPR) pour la livraison et la reprise simultanées avec des temps de trajet et de service stochastiques dans HHC. Pour résoudre le modèle, nous avons d’une part réduit le modèle au cas déterministe. Le solveur de Gurobi, le recuit simulé (SA), l’algorithme de chauve-souris, l’algorithme de luciole ont été proposés pour résoudre le modèle déterministe pour 56 instances respectivement. Enfin, le SA a été adopté pour traiter le modèle SPR. Une comparaison entre les solutions obtenues par les deux modèles a également été réalisée pour mettre en évidence la prise en compte des temps de parcours et de service stochastiques.(3) Pour garantir la qualité du service, sur la base d’un budget de la théorie de l’incertitude, nous avons proposé un modèle d’optimisation robuste (RO) pour HHC Routing, prenant en compte les exigences en termes de temps de déplacement et de service. La vérification de la solution réalisable a été réécrite en tant que fonction récursive complexe. Recherche tabou, SA, Recherche de voisinage variable sont également adaptés pour résoudre le modèle. Un grand nombre d'expériences ont été réalisées pour évaluer le modèle déterministe et le modèle RO. Une analyse de sensibilité des paramètres a également été effectuée. / Home health care (HHC) is a wide range of healthcare services that can be given in one's home for an illness or injury. In recent years, the healthcare industry has become one of the largest sectors of the economy in developed countries. One of the most significant challenges in HHC domain is to assign the labor resources and equipment more efficiently under limited resources. Since the transportation cost is one of the most critical spendings in the company activities, it is of great significance to optimize the vehicle routing problem for HHC companies.However, a majority of the existing work only considers the deterministic model. In the practical of HHC, the decision-makers and caregivers often encounter with uncertainties. So, it is essential to incorporate the uncertainty into the model to make a reasonable and robust schedule for HHC company. This thesis addresses the HHC routing and scheduling problem with taking into account the non-deterministic demand, uncertain service and travel time respectively. The main body the thesis is composed of three independent works.(1) Based on the Fuzzy Credibility Theory, we proposed a fuzzy chance constraint programming (FCCP) model for HHC routing problem with fuzzy demand. This model has both characteristics of combinatorial optimization and FCCP. To deal with the large-scale problem, we developed a Hybrid Genetic Algorithm with the Monte Carlo simulation. Three series of experiments were conducted to validate the performance of the proposed model and algorithm. At last the sensitivity analysis was also carried out the observe the variable parameter involved in the fuzzy decision-making.(2) According to the activity of the caregivers in HHC, we proposed a two-stage stochastic programming model with recourse (SPR) for the simultaneous delivery and pick-up with stochastic travel and service times in HHC. To solve the model, firstly, we reduced the model to the deterministic one. Gurobi Solver, Simulated Annealing (SA), Bat Algorithm (BA), Firefly Algorithm (FA) were proposed to solve the deterministic model for 56 instances respectively. At last the SA was adopted to address the SPR model. Comparison between the solutions obtained by the two models was also conducted to highlight the consideration of the stochastic travel and service times.(3) To guarantee the service quality, based on a budget of uncertainty theory, we proposed a Robust Optimization (RO) model for HHC Routing with considering skill requirements under travel and service times uncertainty. The feasible solution check was rewritten as a complex recursive function. Tabu Search, SA, Variable Neighborhood Search are adapted to solve the model. A large number of experiments had been performed to evaluate the deterministic model and the RO model.

Cette thèse porte sur la planification des tournées de soins pour l'hospitalisation à domicile. Sous l'impulsion des différentes politiques publiques de santé mises en place en France, la demande des patients de recevoir leur traitement dans un environnement familier et sécurisant n'a cessé de croître. Faisant apparaître de nouvelles problématiques d'organisation au sein des établissements d'hospitalisation à domicile, notre travail porte sur l'optimisation de la planification des tournées de soins en considérant des contraintes médicales, logistiques et économiques. Dans un premier temps, nous étudions la planification des tournées de soins hospitaliers à domicile en portant un intérêt particulier aux contraintes de fenêtres de temps et de synchronisation des visites. En rendant ces contraintes souples, nous apportons plus de flexibilité à la modélisation du problème en définissant individuellement les souhaits des patients pour recevoir leurs soins afin d'améliorer la qualité de la planification obtenue et la satisfaction des patients. Dans un second temps, nous intégrons à notre modélisation l'équilibrage de la charge de travail du personnel soignant. Cet aspect ne doit en effet pas être négligé afin d'obtenir une certaine équité et s'assurer de l'applicabilité de notre solution. Par la suite, nous étudions le problème sous sa forme multi-objectif. La hiérarchisation des objectifs pouvant se révéler déroutante pour les décideurs, nous proposons un algorithme mémétique multi-objectif afin d'obtenir un ensemble de solutions représentant différents compromis entre les objectifs. Enfin, la dernière partie de cette thèse s'intéresse à la planification des tournées de soins hospitaliers à domicile dans un contexte multi-centre de soins. La dispersion géographique des patients sur le territoire pouvant entraîner l'ouverture de nouveaux centres de soins, l'affectation des soignants aux centres de soins devient un nouvel aspect à optimiser. Pour chaque problématique, des expériences sont réalisées afin d'évaluer la qualité de nos méthodes de résolution sur des instances de la littérature. / This thesis deals with the planning of care routes for home health care. Under the impulse of the various public health policies put in place in France, the demand for patients to receive their treatment in a familiar and safe environment has steadily increased. Revealing new organizational problems in home health care structures, our work focuses on optimizing care routes planning by considering medical, logistical and economic constraints. As a first step, we study the planning of home health care routes with a particular focus on time window and synchronization constraints. By relaxing these constraints, we bring more flexibility to problem modeling by individually defining the wishes of patients to receive their treatment in order to improve the quality of patient planning and patient satisfaction. In a second step, we integrate in our modeling the workload balancing of the caregivers. This aspect must not be neglected in order to obtain fairness and ensure the applicability of our planning. Subsequently, we study the problem in its multi-objective form. The prioritization of objectives may be confusing for the decision makers, we propose a memetic algorithm for multi-objective optimization in order to obtain a set of solutions representing various trade-offs between the objectives. Finally, the last part of this thesis focuses on the assignment of visits and caregivers to home health care centers in a multi-center configuration. The geographical dispersion of patients on the territory may lead to the opening of new centers, the assignment of caregivers to home health care centers is becoming a new aspect to optimize. For each problem, experiments are carried out in order to evaluate the quality of our solving methods on instances of the literature.

The overall aim of this thesis is to illuminate meanings of the relation between human beings, technology and care, as narrated by critical care nurses and people in need of home mechanical ventilation (HMV). The data are based on narrative research interviews with six intensive care nurses (I), 13 people who were about to start HMV (II), these 13 people were interviewed for a second time six to eight months after HMV had started (III), and nine persons with more than two years HMV experience (IV). The text was analysed using a phenomenological-hermeneutic research method as described by Lindseth and Norberg. The method is developed from the writings of the French philosopher Paul Ricoeur. The findings illuminate meanings of nursing care in an intensive care unit (I) as undertaking the role of advocacy as a caring response to another human being. The basic condition for this caring response depends on the nurses' openness and sensitivity to the needs of patients or patients' next of kin. The nurses were aware of the influence of technology and tried to modify its negative effects. Meanings of becoming dependent on HMV (II) are interpreted and metaphorically expressed as "to get one's breath" and "to hold one's breath" respectively. On the one hand, breathing ensures the cellular oxidation process within the body, but on the other hand there can be "shortness of breath" in "spiritual breathing", and starting HMV will influence patients' whole life situation, body and spirit. After using a ventilator six to eight months, meanings of a life dependent on a ventilator was interpretd as either a closure or an opening of the lived body to oneself, other people and the world. This interpretation is illustrated by two images. A life on a ventilator at home is not to be seen as static being. On the contrary, it is a being which moves and changes over time. Being dependent on a ventilator and living at home, as narrated by adults with more than two years of HMV experience (IV), was interpreted as being able to rise above yourself and your personal boundaries in order to live a good life. These meanings are bound up with experiencing a vital force and interdependency, and despite fragility being able to reach others and the outside world. Design and function of technology had an impact on the lived body. The comprehensive understanding of the four articles (I-IV) unfolded meanings of the relation between human beings, technology and care, as an interchange and a creation of physical and spiritual energy among humans and between human and technology. It could be an experience of the lived body being filled with as well as emptied of energy. This interpretation points at a call for the caring personnel to be attentive and to listen to the voices of the lived body in health and illness, and to bear witness to those who suffer. Technology acts between the person and the world and in order to be embodied, technology must be "transparent", i.e. beautiful and fit to its use.

Det är sjuksköterskans ansvarsområde att uppmärksamma, förebygga och behandla malnutrition. Ädelreformen, där ansvaret för äldre vårdtagare har flyttats från landstingsnivå till kommunnivå, har bland annat inneburit att tillgången till sjuksköterskor i hemsjukvården är liten i förhållande till antal vårdtagare. Detta tillsammans med låg kunskapsnivå om nutrition hos omvårdnadspersonalen om nutrition samtidigt med stor vårdtyngd, har lett till att brister i omvårdnaden inom nutrition kan fortgå en längre tid innan de uppdagas. Syftet var att undersöka sjuksköterskans förmåga att uppmärksamma och åtgärda malnutrition hos äldre vårdtagare inom hemsjukvården och särskilt boende. En litteraturstudie med 20 vetenskapliga artiklar utfördes. Kunskapen om nutrition är överlag låg bland sjuksköterskor och övrig omvårdnadspersonal, bara en liten del av omvårdnadspersonalen kände till metoder för nutritionsbedömning och ännu färre använde nutritionsbedömningen i praktiken. Det individuella energibehovet för de äldre i studierna tillgodosågs inte i de flesta fall men ökat näringsintag med näringsberikad mat eller näringsdryck hade en positiv effekt för att motverka malnutrition. Vidare forskning om svenska förhållanden, där kunskapen hos omvårdnadspersonalen inventeras, skulle vara relevant för vidare utveckling av hemsjukvården. / It is the nurse’s responsibility to observe, prevent and treat malnutrition. The reform of geriatric care, where the responsibility for the elderly residents has been moved from county council into municipality, has implied that access to nurses in Home Care Service is deficient in proportion to the amount of residents. This matter together with poor knowledge in nutrition among the nursing care staff, accompanied by high burden of care, have led to deficiencies in nutritional care, which can remain for a long time before revealed. The aim of the literature study was to examine the nurse’s ability to discover and treat malnutrition in elderly Home Care residents. A literature study based on 20 scientific articles was made. The nutritional knowledge among nurses and members of nursing care staff is generally low, only a small amount of the nursing care staff had knowledge in nutritional screening methods and even fewer used screening methods in practice. The individual requirement of energy for the elderly in the studies was in most of the cases not met, but increased energy intake through energy enriched food or supplement drinks, had a positive effect to counteract malnutrition. Further research in Swedish conditions, where the knowledge among the nursing care staff ought to be inventoried, is highly relevant for further development of the Home Care Services.