Residential care in nursing homes continues to be necessary for those individuals who are no longer able to live safely and comfortably at home. The demographic change with increasing number of persons over 65 years in the next 20 years also means that the percentage of those who will require care in a nursing home some time before the end of their lives will increase. Therefore, anticipating this pressure to expand nursing home availability, it is critical that these services are developed from a profound understanding of what creates the best value. Nursing homes in developed countries have evolved over the past half-century from being places of mainly custodial care to facilities responsible for the management of an ever increasing range of complex nursing and medical conditions. Nursing home residents are frail older adults with complex needs, dependent on advanced nursing care.  Determining what aspect of nursing homes should and can be measured is the current work of many national health care systems. However, uncovering what the nursing home residents perceive as the most important aspects of quality and how they experience living in a nursing home is necessary to develop effective person-centred care.  The overall aim of the present thesis was to contribute to a deeper understanding of quality of care in nursing homes, integrating the professionals’, residents’ and family’s perspectives. The research design is a qualitative approach to explore the concept quality of care and its domains. The thesis comprises a review of internationally used nursing sensitive quality indicators for nursing homes. The indicators are evaluated for their validity as described in the literature. The thesis further describes the residents’ experiences with the interpersonal factors of nursing care quality, as well as the residents’ experiences of living in a nursing home. The thesis also explores the understanding and belief about nursing home quality held by family members of residents. The thesis is based on in-depth interviews of residents in four different nursing homes, and focus group interviews of family members of residents in two different nursing homes. The findings are that quality of care in long-term care in nursing homes encompasses at least four domains: quality of the living conditions, quality of the nursing staff, quality of direct nursing care, and quality of the social environment. Moreover, care quality is influenced by a range of external factors such as the national policy, laws and regulations, management of the organization and the physical building. The local community provides a context in which the nursing home is more or less integrated into. The review of internationally used quality indicators indicate that some factors of care processes and health outcomes for nursing home residents could be measured and give valid and reliable evaluation of the nursing home care quality. In the explorative qualitative study, residents and family placed more emphasis on physical and psychological well-being, interpersonal relationships and the social environment if quality of care is to result. Objective indicators of essential areas of resident-experienced quality need to be developed. This should be done in collaboration with the residents and their next-of-kin, in addition to professional expertise. Methodological and practical implications of the results are discussed. / Sykehjem er en helsetjeneste som vil være nødvendig for eldre som ikke føler seg trygge eller kan få tilstrekkelig behandling, pleie og omsorg i eget hjem. Antall eldre over 65 år er økende i Norge, noe som innebærer et økt press på sykehjem i framtiden. Det er derfor av stor betydning at sykehjemstjenesten utvikles med tanke på å skape best mulig nytteverdi ut fra behov. Sykehjemmene har utviklet seg de siste 50 årene fra hovedsakelig et botilbud til helseinstitusjoner som gir avansert helsehjelp. Sykehjemsbeboere er skrøpelige eldre med komplekse problemstillinger, avhengig av avansert sykepleie. Kvalitetsindikatorer er kvantitative mål som reflekterer en profesjonell standard for pleie og omsorg, og slike mål benyttes i økende grad for å vurdere kvalitet i sykehjem. Imidlertid er det nødvendig å inkludere det som har størst betydning for sykehjemsbeboere i slike mål for å kunne gi god pasientsentrert sykepleie.   Hovedmålsettingen med studien var å bidra til en dypere forståelse av sykehjemskvalitet, ut fra helsepersonellets, beboernes og pårørendes ståsted. Avhandlingen omfatter en oversikt over kvalitetsindikatorer som er i bruk internasjonalt. Videre beskriver avhandlingen beboernes erfaringer med mellommenneskelige faktorer ved sykehjemskvalitet, samt hvordan de erfarer å bo i et sykehjem og opplever kvaliteten på “hjemmet” sitt. I avhandlingen blir også pårørendes forståelse av og meninger om sykehjemskvalitet utforsket. Avhandlingen er basert på dybdeintervju av beboere ved fire ulike sykehjem, og fokusgruppeintervjuer med pårørende ved to av sykehjemmene.   Funnene viser at kvalitet på pleie og omsorg i sykehjem omfatter minst fire hovedområder: Bokvalitet, personellkvalitet, helsetjenestekvalitet og sosial kvalitet. Videre er pleie- og omsorgskvaliteten påvirket av en rekke eksterne faktorer som nasjonale føringer, lovverk, ledelsesstruktur, bygningskonstruksjon og lokale forhold. Den internasjonale oversikten over kvalitetsindikatorer gir indikasjoner på at noen av dem kan brukes som pålitelige og gyldige evalueringer av kvaliteten på pleie og omsorg, samt helserelaterte resultater for beboerne. I den kvalitative intervjuundersøkelsen med beboere og pårørende, ble fysisk og psykisk velvære, mellommenneskelige forhold og det sosiale miljøet tillagt større betydning for kvaliteten. Objektive indikatorer for disse beboererfarte områdene for kvalitet må utvikles. For å sikre at disse er pasientsentrerte, bør utviklingen av kvalitetsindikatorer gjøres i tett samarbeid med sykehjemsbeboerne og pårørende, i tillegg til helsepersonell.

Aim: The overall aim of this thesis was to deepen the understanding of nursing care for seriously ill patients on the edge of life in intensive care unit (ICU) and nursing home when questions were raised whether to withhold or withdraw curative treatment. Method: All studies were conducted in a qualitative frame of reference with interviews of nurses in two contexts in Norway; group interviews of 14 nurses in an ICU (study I, III), and individual interviews of 14 nurses in two nursing homes (study II, IV). Data were analysed with interpretative phenomenology (I, III, IV) and phenomenography (II). Findings: The nurses’ descriptions of the patients on the edge of life were interpreted as ‘being in a twilight zone’, a state between living and dying. The patients’ situation were understood to be very burdensome as they were mostly ‘voiceless’ and unable to call for, or refuse help and totally surrendered to other people’s devices. Their state was strained by extensive suffering; pains and bodily afflictions, loneliness, confusion and without control and dignity (I). Their need for nursing care was comprehensive (I, II) with an overall need for dignity (II), which included having the needs for preparedness, human relationship, comfort and safety met (II). The patients’ inabilities to express themselves clearly involved major challenges for nursing care (I - IV). Good nursing care was described as caring for the individual patient based on his/her situation and needs. The nurses experienced themselves to be of imperative importance for the patient’s living or dying (III, IV) and their interpretation of the patient’s condition was crucial (III). Their commitment and drive to help was high, they knew what good nursing care was for the patients (I - IV), and they were proud when they succeeded in their care (III, IV). An outstanding finding was the nurses’ experiences of ambiguity of both certainty and uncertainty. Being certain mostly seemed to concern nursing care related to the patient’s needs and situation (I, II), and uncertainty to what was ‘right’ to do with regards to withholding or withdrawing treatment (III, IV). They often experienced loneliness, too much responsibility, a vulnerable professional pride, and being pulled between opposite poles when they struggled to give good nursing care (I - IV), but too often they failed (II, IV). This demanding situation sometimes led to the nurses’ use of several self-protecting strategies. Whether the patients could receive good nursing care or not did not only depend on the single nurse, but was also anchored in opportunities and hindrances on a relational and an organisational level (I – IV). There were many congruities in patterns in the experiences of ICU - and nursing - home - nurses with regards to the situation and needs of patients on the edge of life, and good nursing care. Congruities were also found regarding being a nurse when caring for these patients, and nurses’ opportunities and hindrances for carrying out good nursing care. Conclusion: This thesis shows that nursing care was experienced as being of crucial importance to the patients on the edge of life, and the nurses knew very well what good nursing care was for them. However, the nurses’ opportunities to perform good nursing care depended on several preconditions and were restricted by hindrances on different levels, which have to be overcome in order to fulfil patients’ needs and nurses’ ambitions of giving good nursing care. As such, this thesis highlights a wide-ranging understanding of nursing care for these patients, which should challenge individual nurses, but also other health care workers, leaders and politicians.

Syftet med denna deskriptiva litteraturstudie var att beskriva vilken inverkan sällskapsdjur har på äldre personers hälsa och välbefinnande. Totalt 18 vetenskapliga artiklar inkluderades dessa återfanns i databaserna Cinahl, Science Direct och Academic Search Elite samt via andra artiklars referenslistor. Studierna som gjorts om djurens inverkan på äldre personer som bor i det egna hemmet genomfördes med enkäter och intervjuer. Resultatet visade att djurägarna var mindre missnöjda med sin sociala och emotionella situation än de som inte ägde djur. Hos hemmaboende personer med Alzheimers sjukdom visade det sig att interaktioner med sällskapsdjur minskade humör- och psykomotoriska störningar såsom aggression, hyperaktivitet, hallucinationer och känslor av oro. Även en påverkan på den fysiska hälsan hos djurägare återfanns då de fick mer motion än vad icke djurägare fick. Djurägarnas ADL förmåga bibehölls i större utsträckning över tid i jämförelse med de äldre som inte ägde något djur. De flesta studier som gjorts om sällskapsdjurens påverkan på äldre personer inom äldreomsorgen har varit av experimentell karaktär. Sällskapsdjuren hade flera effekter på de äldre; det sociala samspelet och de verbala interaktionerna ökade, känslan av depression och ensamhet minskade. En klar fysisk förbättring kunde påvisas i form av minskade muskelspänningar och trötthet, ökat nutritionsintag och lägre blodtryck. Bland äldre dementa personer påvisades en markant minskning av oro och aggressivitet då de deltog i djurterapi. / The aim of this descriptive literature review was to describe the impact of pets on the health and well being of elderly persons. A total of 18 studies were included which were found in Cinahl, Science Direct and Academic Search Elite and from other article references. Questionnaires and interviews were used to asses the impact of pets on elderly persons living at home. The result showed that pet owners were more satisfied with the social and emotional situation compared to non-pet owners. Persons with Alzheimer’s disease living at home and interacted with pets showed a lesser degree of aggression, hyperactivity, hallucinations and anxiety than non-pet owners. Pets also had an influence on the physical health of the pet owners. They took longer walks more frequently than non-pet owners. Pet owners preserved their ADL to a greater extent compared to non-pet owners. Most studies exploring the impact of pets on elderly living in nursing homes were experimental. Pets had several effects on the elderly; the social connection and the verbal interactions increased, depression and loneliness decreased. Pets also affected the physical condition of the elderly; they had less muscle tensions and fatigue, higher nutritional intake and lower blood pressure. Among the elderly with dementia the anxiety and aggression decreased when they participated in animal assisted therapy.

Tidigare studier visar att människor som bor på särskilt boende ofta lider av depression och ensamhet. Personalen som jobbar på särskilt boende är ofta upptagna med de dagliga sysslorna och tiden för social interaktion med de boende är ofta begränsad. Detta kan resultera i en känsla av övergivenhet och ångest hos den boende. Genom århundradena, så har människan alltid använt sig av husdjur som ett sällskap och tröst. Studier visar att den generella hälsan förbättras och stärks genom umgänget med djur. Syftet med denna studie var att beskriva vårdpersonalens uppfattningar av vad ett husdjur på särskilt boende kan ha för inverkan eller betydelse för vården av de boende. En kvalitativ intervju studie genomfördes för att undersöka studiens syfte. Sju undersköterskor intervjuades. Resultatet visar att husdjur har en positiv påverkan på människan. Det stärker glädjen hos människor omkring och skapar en avslappnande atmosfär. Vårdtagarna på särskilt boende, där ett husdjur bor permanent på avdelningen har uppvisat en lugnande, positiv effekt. Hundar och katter är bland de mest populära sällskapsdjuren på grund av tillfredställelsen det ger att klappa och dess vänliga natur. Det finns dock även nackdelar med husdjur på särskilt boende. Allergier, rädsla för vissa djur och risken för att djuret kan orsaka skada eller att djuret själv kan ta skada förekommer. Författarna anser att det finns behov av fortsatt forskning om husdjur inom vården av äldre. / Former studies show that people living in nursinghomes are often suffering from feelings of depression and loneliness. The staff working at the nursing homes is often occuped with daily chores and the time for social interaction with the residents are limited. This results in feelings of desolations and anxiety. Troughout the centuries, man have always depended on pets as a company and comfort. Studies show that general health improves when interaction with animals occur. The purpose of this study was to describe the staff’s opinion of a pet in nursinghomes and what influence or meaning it may have on the care of the residents. A qualitative interview study was made to examen the purpose of the study. Seven assistant nurses were interviewed. Results show that pets have a positive affect on human beings. They often make people around them feel more joyful and relaxed. The residents in nursing homes, who have experienced a pet living with them at the unit, have showed a calming, positive effect in their behaviour. Dogs and cats are among the most popular animals as a company because of the satisfaction of stroking and its friendly nature. Allergy, fear for some animals and the potential risk for the animal to cause injury to it self or others occurs. The authors acknowledge the need for futher research about animals involved in caregiving.

The purpose of this study was to investigate a nursing home for people who were previously homeless. The study was based on a case study done on the nursing home Gamlebo. The fol-lowing questions were asked, (1) What conditions apply for the job? (2) How is work carried out ? (3) What are the needs of the residents at Gamlebo? (4) What distinguishes Gamlebo from other nursing homes for older people? A qualitative approach was used along with semi-structured interviews. The theory was made with standard theory. The results showed that the staff at Gamlebo had the potential to work through clear guide-lines that took into account the residents' individual needs. Work was conducted with individ-ual solutions and most importantly a good treatment. A good treatment was according to the staff crucial when working with the residents. The residents were characterized by their homelessness and had a distrust of society. To create trust towards the residents was therefore crucial and to wait out the residents own will. What distinguishes Gamlebo from other tradi-tional nursing homes is that the staff has the expertise and experience to meet older people who have been homeless in their own terms.

No description available.

Demens är en vanlig diagnos hos äldre personer i Sverige. Syftet med denna studie var att undersöka hur och varför omsorgspersonal på en gruppbostad för personer med demens använder sig av klargörande kommunikation i det dagliga omsorgsarbetet. Studien har en etnografisk ansats, och datainsamlingsmetoden är deltagande observation. Deltagande observation möjliggjorde att fånga omsorgspersonalens agerande under det dagliga omsorgsarbetet för personer med demens. Studiens resultat visar att omsorgspersonalen använder klargörande kommunikation i olika syften. Syftena var att undvika oönskat beteende hos de boende, uppmana till önskvärd aktivitet hos de boende samt för att hjälpa boende som ger uttryck för desorientering. Omsorgspersonalen agerar klargörande genom att hänvisa till situationens kontext och till de aktiviteter som är lämpliga i stunden. Omsorgspersonalen agerar även klargörande genom att ge de boende tydliga instruktioner och information utifrån omsorgspersonalens kontext när de boende ger uttryck för desorientering. Kunskaper från studien för tillämpning i praktisk omsorg inom gruppboende för äldre är att sätta ord på omsorgspersonalens klargörande omsorgshandlingar samt kunskaper om vilka dessa handlingar är. / Dementia is a common diagnosis among elderly people in Sweden. The aim of this study was to examine how and why caregivers at a nursing home for people with dementia use clarifying communication in the daily care. This study has an ethnographic approach, and the data have been gathered by use of participant observation as a method enabled us to capture the caregiver’s actions during daily care for the people with dementia. The results show that the caregivers used clarifying communication in different purposes. The purpose was to stop the persons with dementia from unwanted behaviour, to encourage the persons with dementia to desirable activities and to help the persons with dementia when they express disorientation. The caregivers acted clarifying by referring to the context of the situation and by referring to appropriate activities. The caregivers also acted clarifying by giving the persons with dementia clear instructions and clear information by the caregiver’s point of view when the people with dementia expressed disorientation. Knowledge from this study for implication in care in nursing homes for elderly people is to name the caregivers clarifying actions and knowledge about witch these clarifying actions are.

This dissertation consists of two essays examining formal and informal long term health insurance markets. The first essay analyzes heterogeneity of Long-Term Care Insurance policyholders in their lapse decision, and how their ex-ante and ex-post subjective beliefs about the probability of needing Long-Term Care affect their lapse decisions. In this essay, I develop a model of lapse decision in a two-period insurance framework with a Bayesian learning process and implement several empirical specifications of the model using longitudinal data from the Health and Retirement Study. The results show that policyholders' ex- ante point predictions of their probabilities and their uncertainties about them have a persistent but declining impact on lapse decisions. Those who believe that their risk is higher are indeed more likely to remain insured. However, as their uncertainties surrounding their ex-ante point predictions increase, their chances of lapsing increase regardless of their initial perception biases. These results are heterogeneous across cohorts and policyholders and, in particular, show that those in the older group near the average age of Nursing Home entry have a precise prediction of their risk levels compared to the younger cohort. Policy simulations show that a more informed initial purchase decision reduces the chance of lapsing down the road. The second essay examines the extent to which informal risk sharing arrangement provides insurance against health shocks. I develop a comprehensive model of informal risk sharing contract with two-sided limited commitment which extends the standard model to a regime with the following features. Information regarding the nature of realized health shocks is imperfect and individuals' health capital stock serves as a storage technology and is a factor of production. The theoretical results show that, in such a regime, Pareto optimal allocations are history dependent even if participation constraints do not bind. I perform numerical analysis to show that risk sharing against health shock is less likely to be sustainable among non-altruistic individuals with different levels of biological survival rates and health capital productivity. The results also show that optimal allocations vary depending on the set of information available to individuals. Using panel data of households from villages in rural Ethiopia, I test the main predictions of the theoretical model. While there is negative history dependence in transfers among non-altruistic partners, history dependence is positive when risk sharing is along bloodline and kinship. However, neither short-term nor long-term health shocks are insured through informal risk sharing arrangements among non-altruistic individuals.

Bakgrund: Antalet personer över 80 år kommer att öka dramatiskt under de närmaste decennierna. Allt fler äldre blir beroende av vård på äldreboende. Joyce Travelbees omvårdnadsteori används för att förklara omvårdnadsprocessen och den mellanmänskliga relationen för att uppnå en god omvårdnad. Syftet: Syftet med litteraturstudien var att belysa hur det är att vara äldre och bo på ett äldreboende. Metod:Studien genomfördes som en allmän litteraturstudie, baserad på 14 vetenskapligt granskade artiklar. Datainsamlingen genomfördes i elektroniska databaser. Artiklarnas tillförlitlighet granskades enligt Röda Korsets Högskolas granskningsmall. Resultat: Tre kategorier framkom: upplevelsen av den egna kroppen, upplevelsen av den sociala miljön och upplevelsen av relationen till vårdgivaren. Att bli sedd och skapa en god relation till vårdpersonalen var viktigt för den äldre. Resultatet visar att kroppsförändringar är ett känsligt ämne för den äldre och att behovet av hjälp var svårt att acceptera. Äldreboende uppfattades av många som isolerande och rutinmässig. Diskussion: De utmärkande fynden kommunikation, kroppsliga förändringar och relationen till vårdpersonalen diskuteras. Slutsats: En uppenbar förändring behövs inom äldreomsorgen för att de äldre ska få ett värdefullt liv. / Background: The number of people over 80 will increase dramatically over the coming decades. More and more elderly people will become dependent on care in nursing homes. Joyce Travelbees nursing theory was used to explain the nursing process and the interpersonal relationship in order to achieve good health care. Aim: the purpose of this study was to elucidate what it means to be elderly and to live in a nursing home. Method: The study was conducted as a literature study, based on 14 peer-reviewed articles. Data was collected in electronic databases. Reliability of all articles was reviewed using the Red Cross University College’s audit template. Results: Three categories emerged: the experience of the own body, the experience of the social environment, and the experience of the relationship with the caregiver. Being seen and creating a good relationship with caregivers was important for the elderly. The results show that body modification is a sensitive topic for the elderly, and that they have difficulties accepting the need of help. Nursing home was perceived by many as being insulating and routine. Discussion: The characteristic findings of communication, bodily changes and relationship to the nursing staff are discussed. Conclusion: Obvious change is needed in elderly care to create a useful life.

<b>Background. </b> Although antipsychotic medications are primarily intended to treat schizophrenia and psychotic symptoms in adults, they are commonly administered to nursing home residents as pharmacotherapy for "off-label" indications such as disruptive behaviour. However, clinical trials have demonstrated limited efficacy and serious side-effects of antipsychotics among the elderly. As previous studies have reported inappropriate use in several countries, their use in nursing home residents ought to be monitored to detect and reduce inappropriate administration. <br /><br /> <b>Objectives. </b> The aim of this study was a) to determine and compare prevalence rates of antipsychotic use in Ontario and Swiss nursing homes, b) to identify determinants of antipsychotics use in these two countries, by means of a cross-sectional design, and c) to investigate the impact of antipsychotic use on behaviours over time in Ontario and Swiss residents, by means of a longitudinal design. <br /><br /> <b>Methods. </b> This study involved secondary data analysis of 1932 residents from 24 nursing homes in the province of Ontario in Canada and 1536 residents from 4 nursing homes in a German-speaking canton in Switzerland. Residents were assessed with the Minimum Data Set (MDS) tool. Resident characteristics and prevalence rates were compared internationally with the chi-square test. Demographic and clinical determinants of antipsychotic use, as well as behavioural change associated with antipsychotics, were analyzed using logistic regression. <br /><br /> <b>Results. </b> Although Ontario nursing home residents had an overall heavier-care profile than Swiss residents, antipsychotics were administered to 25% of the Ontario residents compared to 29. 5% of the Swiss residents. The adjusted rate among residents without appropriate conditions was also lower in Ontario (14%) than in Switzerland (24. 5%). Apart from schizophrenia, bipolar disorder and cognitive impairment, antipsychotic use was determined by a different range of characteristics in these two countries. Antipsychotic use was not predictive of behavioural improvement. <br /><br /> <b>Conclusion. </b> The high adjusted rates of antipsychotic use in Ontario and Swiss nursing home residents, as well as the presence of "inappropriate indications" and "facility" as determinants of their use, raise concerns about the appropriateness of their administration in both countries. Their lack of effectiveness to improve behaviours also questions their use as long-term treatment for behaviour disturbances. Changes in practice patterns and implementation of policies are warranted to reduce inappropriate prescribing practices to enhance the quality of care provided to residents in nursing homes.