Graduation date: 1997

The overall objective of this research was to analyze the effect of ownership status on 1) quality of care delivered, 2) the cost of nursing homes in the United States and 3) wages to Registered Nurses. The model developed here uses a two stage least squares technique to correct for observed endogeneity problems. Results show that a model which includes ownership classification interactively with all independent variables, performs better than a model which simply uses dummies to proxy for ownership status. Nonprofit homes were found to have higher direct patient care expenditures than profit homes. Non-profits were also found to have a more specialized nursing force. Both of these results suggest that non-profits may actually provide a higher quality of care than for profit enterprises. No support was found for the hypothesis that nonprofits have more philanthropic wage policies. / Graduation date: 1996

Thesis (Ph. D.)--Illinois State University, 2005. / Title from title page screen, viewed on April 22, 2007. Dissertation Committee: Gary L. Creasey (chair), Jeanne A. Howard, Susan L. Smith, Adena B. Meyers, Alvin E. House. Includes bibliographical references (leaves 141-154) and abstract. Also available in print.

The thesis focuses on the nurse and her practice in end-of-life care in the field of palliative home care. The overall question is how nurses come to do what they do within this practice and where they get the practice, which can also be expressed as the  genesis and structure of the practice. The thesis’ social relevance takes its starting point in the Swedish Elderly Care Act (Ädelreformen) and theoretical inspiration from Foucault’s discourse analysis regarding the establishment of the clinic. The thesis has a practice-theoretical approach in which Bourdieu’s habitus concept, explaining how practice is generated, is central. The habitus concept can be described as a set of subjective dispositions in the individual that prompt her to act in a certain way. These dispositions are expressed in attitudes, strategies, and capacities and can be seen in relation to the practice structure. The thesis’ method is based on observations, conversations, and interviews with the nurses about their work, education, and social background. Conversations between the nurses and the spouse living with the sick person were recorded and transcribed. Encompassed by the study were six nurses, whose work was followed for seven months in 13 private homes. The actions performed by the nurses in their practice proved to be homogenous, a circumstance they were not aware of. There was agreement between the nurses’ underlying structure and how they handled their practice, i.e. the end-of-life care in the private home. The nurses had similar ideals and had developed similar habituses as they grew up and during their adult lives. The thesis is empiric in that the reader follows the nurse in her work in private homes. The nurse organizes this care in the home in consultation with the patient and the person living with them in an extraordinarily cautious manner. How the nurse handles difficult situations and conversations with spouses and often dying patients, is viewed in relation to the nurse’s habitus and dispositions. Key words: nurse, palliative home care, practice theory, habitus, observation, pedagogical practice, Bourdieu, Foucault / Lokal för dispuation ändrad till Universitetshuset sal X.

Socialtjänsten har ett ansvar för att se till att familjehemsplacerade barn får en trygg och bra uppväxt. Syftet med uppsatsen är att skapa en förståelse och en ökad kunskap kring hur väl socialtjänsten tar det ansvaret. Enligt tidigare forskning finns en del brister i familjehemsvår-den. För att ge en bild av socialtjänstens uppföljningsarbete med familjehemsplacerade barn har jag använt en kvalitativ intervjumetod och intervjuat familjehemsföräldrar och social-sekreterare kring tolv familjehemsplacerade barn. Några resultat är att socialtjänsten vanligtvis föjer upp placeringarna två gånger om året med hembesök där man pratar med barnet, att man i liten utsträckning använder någon strukturerad metod vid uppföljningen, att socialtjänsten oftast arbetar aktivt med barnets kontakt med de biologiska föräldrarna samt att socialtjänsten oftast har upprättat vårdplaner kring barnen. Det finns många faktorer som påverkar arbetet. Några av dem är barnets behov, tilltro till familje-hemmet, intressekonflikter, socialtjänstens organisation, ekonomiska resurser och personliga egenskaper hos socialsekreterarna. Resultaten har jämförts med tidigare forskning och analyserats utifrån systemteori och rollteo-ri. En slutsats är att det trots förändringar i lagstiftningen, där barnperspektivet blivit starkare, är svårt att förändra socialtjänstsystemet och anta en stark roll som barnets företrädare.

The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients. Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged. The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.

A multi professional team use different professional skills to a specific target. The people in the team complement each other to achieve the best performance possible. Professional identity is a mix between the professional and personal identity. Social identities, like professional identity, is a product of social categorization and social comparison. The purpose of this study was to examine how increased cooperation in cross-disciplinary teams has affected the professional identity of home care staff. The method I used to gather my material were focus groups with home care staff in relation to their workplace. Five focus groups were conducted and formed the basis of the results. I used parts of and got inspired from the hermeneutic approach in the analysis of my empirical findings. The results were interpreted by the social identity theory and the concepts of identity, professional identity and the dual task. The results show that home care staff finds it difficult to describe what their role is in the profession. The team's work has affected the staff to feel stronger in their profession and occupation. They have been able to learn from the other team members and have got a deeper understanding of the other team member’s profession. They also believe that the home care staff group has become more of a united group now that they know more about each other's work, work more equal and have more discussions within the group. Home care staff professional identity has been influenced, as all work within the team goes toward a common explicit goal. This has made stronger professional identity within the group and they can identify themselves more with each other. The teams work towards the common goal has also contributed to that they experience cooperation, understanding and affinity with the other team members. This has broadened their professional identity and they have become part of a new group - the team.

Syftet var att beskriva hur sjuksköterskor inom palliativ hemsjukvård uppfattar ochlindrar andnöd hos cancerpatienter i sen palliativ fas. Metoden var kvalitativ med fenomenografis ansnats. Sex informanter från två palliativa hemsjukvårdsteam i Mellansverige valdes ut och intervjuades. Resultatet som representerar informanternas olika uppfattningar bestod av de fem kvalitativt skilda beskrivningskategorierna: Diskrepans i uppfattningen av andnöd som vanligt förekommande och svårt. Fysiska och psykosociala faktorer orsakar andnöd. Stödjande faktorer är betydelsefulla för sjuksköterksans arbete. Känsla av osäkerhet och otillräcklighet. Medicinska åtgärder prioriteras framför omvårdnadsåtgärder. Slutsats: Studien visade att andnöd var ett komplext symtom som kräver enn mångfacetterad kompetens. Det framgår också att läkarstöd, kollegialt stöd, manualer, handledning oc erfarenhet stärkte informanternas omvårdnadsarbete och ökade förutsättningarna för att patientens andnöd lindrades på ett adekvat sätt. En god tillgång till de olika stödfaktorerna ökade dessutom informanternas möjlighet att hantera den ansträngda situation som uppstod i patientens hem.

Bakgrund: På senare tid har närståendes roll i vården fått en ökad betydelse. I Sverige insjuknar varje år 50 000 individer i cancer. När sjukdomen övergått i sen palliativ fas väljer allt fler patienter att vårdas den sista tiden av livet i hemmet. Mer ansvar läggs därigenom på närstående vilket lett till ett ökat behov av stöd åt närstående. Syfte: Syftet med litteraturstudien var att belysa närståendes upplevelse av stöd när en familjemedlem med cancer vårdas i sen palliativ fas i hemmet. Metod: Studien är en litteraturöversikt baserad på vetenskapliga artiklar från tidigare forskning. Resultat: Resultatet visade att närståendes upplevelse av stöd fanns i att klara av vardagen och att kunna förbereda sig för framtiden. Däremot framkom även att närstående upplevde avsaknad av stöd, som fanns i att känna sig otillräcklig och att känna sig övergiven. Närstående upplevde information kring familjemedlemmens sjukdom, vårdandet av den döende samt vad närstående kunde förvänta sig av framtiden framkom som ett stöd av betydelse. Närstående upplevde sig inte bli sedda av professionella vårdgivare vilket bidrog till att närstående kände sig ensamma i den svåra situation dem befann sig i. Slutsats: Då närstående befinner sig i en situation där deras behov av stöd inte alltid tillgodoses, är det av vikt att professionella vårdgivare i alla avseenden inkluderar och uppmärksammar närståendes individuella behov av stöd. / Background: The role played by next of kins in the public health care system has, of late, become increasingly important. Every year 50,000 people contract cancer in Sweden. During the final stages of life, when the illness has reached the late palliative phase, an increasing amount of patients choose to be nursed at home. Subsequently, more responsibility is placed upon relatives and their need of support increases. Purpose: The purpose with this study was to illustrate next of kin’s experiences of support when a member of the family suffering from cancer was nursed at home during the late palliative phase. Method: The study is an overview of literature based on scientific articles from previous research. Findings: The study’s findings show that next of kins experienced most support in situations associated with coping with the daily chores or when having to prepare themselves for the future. However, next of kins also experienced a lack of support and reported feeling insufficient and abandoned. Information about the family member’s illness and nursing of the same as well as a comprehension of what they, as next of kins, might expect of the future constituted a significant support. Nevertheless, they felt ignored in contacts with professional health care providers which contributed to a feeling of loneliness. Conclusion: When next of kins find themselves in a situation where their needs of support is not always fully satisfied, it is of great importance that professional health care providers notice and include the next of kins individual needs of support in all respects.

Sammanfattning Syftet med studien var att utifrån distriktssköterskors berättelser beskriva deras arbete med palliativa patienter inom hemsjukvård samt deras upplevelse av arbetet. Studien hade en beskrivande design och tio distriktssköterskor från fem olika hälsocentraler i Mellansverige deltog i studien. Data samlades in via semistrukturerade intervjuer och analyserades utifrån kvalitativ innehållsanalys. Resultatet redovisas utifrån kategorier som bildade två teman. Temat ”Att balansera mellan nuet och planera slutet – att vara steget före” framkom ur kategorierna Att se patientens livssituation och utföra omvårdnadsåtgärder, Att strukturera arbetet, Att stödja och ha kontakt med närstående, Att uppleva utvecklings och utbildningsbehov samt Att vara professionell i sitt förhållningssätt och beskriver distriktssköterskornas upplevelse av att vårda palliativa patienter. Distriktssköterskornas insatser hos patienten intensifierades allteftersom sjukdomen fortskred, kontakten med närstående och andra vårdgivare beskrevs som god. Temat ”Att uppleva stimulans och påfrestningar” bildades ur kategorierna Att vara professionell i sitt förhållningssätt och Att uppleva och hantera egna känslor och beskriver distriktssköterskornas egna känslor inför att vårda palliativa patienter. Distriktssköterskorna upplevde sitt arbete som värdefullt och viktigt, dock upplevdes det som påfrestande med flera palliativa patienter samtidigt samt att det var extra jobbigt med yngre patienter. / Abstract The aim of the study was to describe district nurses’ work with palliative patients in home care and their experience of the work. The study had a descriptive design and ten district nurses from five different health care centres in the Middle of Sweden participated in the study. Data were collected with semi-structured interviews and analysed with qualitative content analysis. The results are presented from the categories, which formed two themes. The theme “To balance between the prevailing situation and to plan the end – to lie ahead. emerged from the categories To see the patient’s life situation and to perform nursing interventions, To structure the work, To support and have contact with relatives, To experience developmental and educational needs and To be professional in one’s approach and describes the district nurses’ experience of caring for palliative patients. The district nurses’ efforts at the patients home were intensified as the disease progressed, the contact with the relatives and other caregivers were described as good. The theme “To experience stimulation and strain” emerged from the categories To be professional in one’s approach and To experience and handle one’s own feelings and describes the district nurses’ feelings about caring for palliative patients. The district nurses experienced their work as important and valuable; however it was also experienced as trying with several palliative patients at the same time and extra tough when the patients where younger.