The Swedish Agency for Higher Education evaluated in 2007 the nursing programs at Swedish Universities, and confirmed that several programs lacked definition of the main subject of the discipline;- namely caring- and/or nursing. The caring science disciplines showed indications of increasing signs of fragmentation, in that sub-disciplines were evolving. There is a unique foundation of theoretical knowledge that is specific for the caring professions grounded in caring theory and philosophy. For some reason the theoretical foundation and contexture of providing care seems to fade off with time in clinical practice, as well as an explicated theory-practice gap; that theory does not go along with clinical practice. An assumption in this thesis is that caring theory somehow seems to evaporate; as nurses become clinically active- caring theory does not seem to be much reflected upon.The overall aim was to investigate into the meaning of caring to nurses in municipal elderly care, and into their explicit and implicit understanding of caring theory in their daily practice.The theoretical perspective was caring science, while the epistemological frame was of a phenomenological hermeneutical life world approach. Data was gathered by interviews with nurses working in elderly care and analyzed to grasp the structure of the phenomenon of caring in theory and practice. The thesis comprises four studies of which three empirical was consolidated with a Jean Watson’s specific caring theory, ending up in a better understanding of the approach of caring in nursing and the role of theory in practice. The findings of the studies show that the lived experience of caring as narrated by the participating nurses comprises both implicit and explicit theoretical foundation to existential caring theory. The explicit use of theory or certain theoretical affiliation was not obvious; rather what may be theoretical inputs was expressed as the importance of being present and the necessity of having a health perspective in caring. By illuminating caring and concepts from caring theory, the meaning of caring in their professional lived experience, the primary intention or choice of working as nurses became apparent again. There seems to be different perspectives related to caring theory, but as the empirical findings shows, there is a consensus behind what caring is, both in theory and in practice. As a result from the analysis the aim of caring itself may be more salient and focused if based on existential phenomenological caring concepts and theory, as this corresponds with the nurses understanding of holistic intentional caring with a health perspective. A gap exists, but is more related to organizational restrictions such as role constraints and time pressure than to the meaning of caring in theory and practice. Mediating care is a concept that embraces the implications of all the outcome concepts of the analysis and it has the possibility of being the expression of immanent and transcendent dimensions in caring. Mediating care represents the expression of our understanding of life, our values and norms. It is given expression through the insights into, and the ways we connect to one another, our ability as carers (nurses) to reach out to another in his or her being, as well the understanding of ones own being in caring. Theoretical and practical reflection and cultivation of clinical sensibility has the opportunity of inspiring for an expanded caring consciousness, manifested in the mediation of care.

The purpose of this study has been to examine the unit manager’s perspective on making Lex Sarah-notifications. The study has been carries out by six semi structured interviews with persons in leading positions of the elderly from three different municipalities. They were asked about different circumstances that affects the problems with Lex Sarah. The results indicates that the unit manager’s act on elder abuse from the complex mechanisms that exist within the organization. The study results shows that the unit manager’s in the daily tasks are doing their work and solve problems regarding the risk of elder abuse that occur over time, but circumstances will determine if its documented prescribed by a Lex Sarah. The conclusion is that the unit manager’s of the elderly is limited by the circumstances and processes within the organization and that it affects them to lift up and report abuse among the elderly.

Background: In pace with the increasingly aging population will the number of older people in nursing homes and with care in home grow. This means that the nurse will face related to the older more frequently and more widely. Nurses has overall responsibility over both the care of the elderly as a responsibility of maintaining good relationships with related parties. Related parties are of great importance for the older individual, it is therefore relevant for the nurse to be able to interact in a respectful and sensitive manner to involve the relatives in care. Aim: The aim with this study was to highlight nurse's experiences of interaction with related parties to elderly in community health care. Method: A literature review based on nine qualitative articles was conducted. Friberg design was used with the inspiration of Lundman and Hällgren Graneheim regarding the analysis of Articles. Results: The study resulted in four themes. They included information about nurse's experiences of interaction with related parties. These themes describes the importance of communication in the interaction, the attitudes various expressions, cooperation with related parties and experiences with related parties' participation in care. Conclusion: An important conclusion is that the nurse should take advantage of related parties skills and resources in health care around the elderly. The nurses sometimes has difficulties interacting with related parties. Nurses probably need to see the difficulties from different perspectives and seek help of colleagues.

The aim of this study was to describe how the concept of everyday rehabilitation (ER) is perceived in municipal elderly care. Data was collected through individual interviews with nurses assistans, occupational therapists, department managers and politicians, five to six respondents in each group of professionals. The study design was qualitative and based on content analysis inspired by phenomenography. The analysis resulted in two categories: 1) ER implies communication, co-operation and resources, and 2) ER implies that in all situation enable and support training by activity. All respondents stated that the concept of ER means that the elderly within municipal long-term care should have the opportunity to perform activities according to their own ability. Other significant aspects were that ER is considered to imply good communication and be an obvious approach not in need not be discussed. Finally, education is considered important but not a prerequisite to be able to work according to everyday rehabilitation. / <p>Validerat; 20120613 (anonymous)</p>

Bakgrund: För att ge god och säker vård behövs ett säkert och strukturerat sätt att kommunicera mellan olika vårdgivare. Kommunikationsverktyget SBAR skall enligt Sveriges kommuner och Regioner, implementeras inom kommunal verksamhet.Sjuksköterskor och omvårdnadspersonal har behov att kunna rapportera utifrån en patientsäker struktur där patientinformation sker mellan olika vårdgivare och inom den egna verksamheten.Syfte: Syftet med studien var att beskriva sjuksköterskors erfarenheter av att införa och använda kommunikationsverktyget SBAR inom kommunal äldreomsorg. Metod: Studien hade en beskrivande design med kvalitativ ansats. Datainsamlingen skedde genom semistrukturerade intervjuer med åtta sjuksköterskor inom kommunal äldreomsorg. Analys gjordes med en manifest innehållsanalys.Huvudresultat: I resultatet framkom två kategorier och fyra subkategorier.De två kategorierna var hinder och förutsättningar vid införandet av SBAR och hinder och förutsättningar för användandet av SBAR. Sjuksköterskorna upplevde att SBARutbildningen liknade en kortfattad information, inte som en utbildning i ett nytt kommunikationsverktyg. De saknade uppföljning och att ny personal fick utbildning i SBAR. Samtliga sjuksköterskor uppgav att SBAR skulle ha fungerat bättre om fler inom organisationen, dvs omvårdnadspersonal, använde det, samt att det var fördelaktigt och användbart då kommunikationsverktyget har en tydlig struktur på vad som ska rapporteras. Sjuksköterskorna beskrev att det var stor variation i hur och antalet omvårdnadspersonal som använde och rapporterade utifrån SBAR. Detsamma gällde för sjuksköterskorna.Slutsats: Studien visar att det finns vissa steg i implementeringsprocessen som bör utvecklas och förstärkas och att det är viktigt och värdefullt att involvera vårdpersonalen i samtliga steg. Genom att involvera personalen kan införandet och användandet underlättas. / Background: In order to provide high-quality, safe care, a safe and structured way of communicating between different care providers is needed. According to Sweden's municipalities and regions, the communication tool SBAR must be implemented in municipal operations. Nurses and nursing staff need to be able to make their reports based on a patient-safe structure, both when there is a transfer of patient information between different care providers, and within their own operations.Aim: The aim of the study was to describe nurses' experiences of introducing and using the communication tool SBAR in municipal elderly care.Method: The study had a descriptive design with a qualitative approach. The data collection took place through semi-structured interviews with eight nurses in municipal elderly care. Analysis was conducted using a manifest content analysis.Main results: The results showed two categories and four subcategories.The two categories were obstacles and conditions for the introduction of SBAR and obstacles and conditions for the use of SBAR. The nurses felt that the SBAR training was similar to a brief information, not equivalent to receiving training in using a new communication tool. They lacked follow-up, and new staff lacked training in SBAR. Allnurses stated that SBAR would have worked better if more people within the organization, i.e. nursing staff, used it, and that it was beneficial and useful as the communication tool provides a clear structure for what is to be reported. The nurses described that there was great variation in the number of nursing staff who used SBAR for their reports, and in the way it was used. The same was true for the nurses.Conclusion: The current shows that there are certain steps in the implementation process that should be developed and strengthened, and that it is important and valuable to involve the care staff in all steps. By involving the staff, the introduction and usage can be improved.

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.

SAMMANFATTNING Att arbeta som sjuksköterska inom den kommunala äldrevården är en svår uppgift, då sjuksköterskan ofta upplever stor frustration över att vara den "ensamma fixaren". Att vara den "ensamma fixaren" kan beskrivas som att kunna allt och vara överallt, medan man samtidigt känner sig underskattad och osynlig. Sjuksköterskorna riskerar på grund av detta, att göra misstag och utveckla sjukdom på grund av stress. Syftet med denna studie var att undersöka sjuksköterskors upplevelse av stress i sin arbetssituation inom kommunal äldrevård. Studien hade en kvalitativ deskriptiv design och data samlades in med hjälp av enskilda intervjuer med sex sjuksköterskor. Materialet analyserades enligt Graneheim och Lundmans kvalitativa innehållsanalys. Resultatet visade att sjuksköterskorna upplevde oförutsedda händelser som stressande, då de även hade planerade ärenden sedan tidigare. Övrig vårdpersonal och anhöriga ställde ibland högre krav än vad sjuksköterskorna kunde motsvara vilket gjorde sjuksköterskorna frustrerade. Sjuksköterskorna hade även egna krav som inte kunde motsvaras och att verksamheten inte alltid gav förutsättningar för att sjuksköterskorna skulle kunna utföra ett bra omvårdnadsarbete utifrån sina ideal vilket kan leda till moralisk stress. Sjuksköterskorna upplevde en för hög arbetsbelastning och för mycket stress i sin arbetsmiljö. Vidare visade resultatet att sjuksköterskan upplevde brister i patientsäkerheten såsom läkarbristen, att ej kunna ge en säker läkemedelshantering och att inte hinna skriva och bearbeta avvikelser. Att arbeta under tidspress och stress är påfrestande, både fysiskt och psykiskt, och kan på sikt påverka sjuksköterskornas hälsa och därmed även patientsäkerheten negativt. Att arbetsgivaren erbjuder kunskap i stresshantering och arbetar stressförebyggande är därför av vikt.

Introduktion: I takt med samhällets tekniska utveckling ökar även implementering av tekniska lösningar i vård och omsorg. Den ökade teknikanvändningen påverkar både vård- och omsorgspersonal och den äldre. Syfte: Syftet var att beskriva vad som påverkar vård- och omsorgspersonalens attityder till tekniska lösningar och upplevelse av hur teknikanvändning påverkar den äldres dagliga liv. Metod: En intervjustudie med induktiv ansats genomfördes med n = 12 vård- och omsorgspersonal i en mellanstor kommun i Mellansverige. Kvalitativ innehållsanalys resulterade i åtta huvudkategorier: arbetssituation, kompetens, delaktighet, självständighet, trygghet, frihet, social kontakt och hälsa. Resultat: Vård- och omsorgspersonalens attityder till tekniska lösningar var både positiva och negativa och påverkades utifrån deras arbetssituation, känsla av kompetens och delaktighet. Vård- och omsorgspersonalen upplevde att teknikanvändningen påverkade den äldres dagliga liv genom att deras självständighet, trygghet, frihet och hälsa ökade. Samtidigt upplevde vård-och omsorgspersonalen att teknikanvändning kunde leda till ökad känsla av ensamhet hos den äldre. Konklusion: Studiens slutsats är att vård- och omsorgspersonalen överlag hade positiva attityder till tekniska lösningar och de upplevde att teknikanvändningen påverkade den äldre både positivt och negativt i det dagliga livet. Med anledning av det ansåg vård- och omsorgspersonalen att det är viktigt att teknikanvändningen individanpassas. / Introduction: In step with society´s technical development, the implementation of technical solutions in health and care also increases. The increased use of technology affects both the health and care staff and the older adult. Aim: To describe what affects health and care staff´s attitudes to technical solutions and howthe use of technology affects the older adult´s daily life. Method: An interview study with an inductive approach was conducted with n = 12 health andcare staff in a mid-sized municipality in the middle of Sweden. The qualitative content analysis resulted in eight main categories: work situation, competence, participation, independence, sense of security, freedom, social interaction and health. Result: The attitudes of health and care staff towards technical solutions were both positive and negative. Their attitudes were affected by their work situation, competence and participation. The health and care staff´s experience was that the use of technical solutions affected daily life of the older adult by increasing their independence, sense of security, freedom and health. At the same time health and care staff experienced an increased sense of loneliness of the older adult. Conclusion: The conclusion of the study is that the health and care staff had positive attitudes towards technical solutions and they experienced that the use of technic usage affected the daily life of the older adults, both in a positive and negative way. Because of this it was important to individually adapt the solutions. / DigitalWell

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.

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>