The majority of individuals in nursing homes have cognitive-communication impairments which impact quality of care because direct care providers, certified nursing assistants, (CNAs) are unsure how to respond to resident’s communication behaviors. One intervention that facilitates staff-resident communication in nursing homes is communication plans; however, the research to date about communication plans has not specifically involved CNAs. The purpose of this study, using a grounded theory qualitative approach, was to describe development, implementation and evaluation of communication care plans (CCPs) for residents with cognitive-communication impairments in nursing homes by CNAs who did and did not receive professional support. Communication care plans are communication plans with the addition of autobiographical information. Twenty residents and ten CNAs from two nursing homes participated in the study. Once CCPs were created, CNA participants in one facility received support each day. Following two weeks, CNAs participated in a semi-structured interview. Interviews were transcribed and analyzed using open, axial and selective coding. Findings revealed a core category, meeting resident’s needs through professional support and communication, which describes the progressive process these CNAs underwent to effectively communicate with residents in nursing homes using CCPs. Evolution of this process occurred as CNA participants became familiar with residents. An underlying component facilitating this familiarity was support during CCP implementation. Initially, these CNAs had negative views about nursing home care because they were unsure how to communicate with residents and received little support from higher levels of nursing authority. Over time and with application of CCPs, CNAs became familiar with residents and their communication behaviors. Application of specific communication strategies on CCPs required ongoing support from the investigator/speech-language pathologist which was evident by the comments between CNA participants from each facility. Participants from both facilities reported positive experiences during application of the autobiographical information on the CCPs. This personal information coupled with increased knowledge about resident’s specific communication abilities fostered the formation of a relationship between residents and CNAs. In summary, support during application of CCPs supplements CNAs’ abilities to meet residents’ needs.

Socialstyrelsens brukarundersökning visar att äldre som bor på särskilt boende är mest missnöjda med de aktiviteter och den sociala samvaron som verksamheten erbjuder. Äldreomsorgen bygger på den nationella värdegrunden som innefattar att den äldre ska få leva ett värdigt liv och känna välbefinnande, men det är inte klart hur denna värdegrund påverkar personalens arbetssätt eller de sociala aktiviteter som erbjuds. Vår studie angriper denna fråga. Fem särskilda boenden var representerade både från kommunala och privata vårdgivare i två olika kommuner. Semistrukturerade intervjuer genomfördes med de särskilda boendes enhetschefer, som sedan transkriberades och tematiskt analyserades. Vårt resultat tyder på att den nationella värdegrunden inom äldreomsorgen tolkas olika på alla de särskilda boendena. Alla enhetschefer la stor vikt på personcentrerad vård, men trots det så erbjöd man liknade sociala aktiviteter ofta då som gruppaktivitet. Resultaten diskuterar vi med hänvisning till Aktivitetsteorin och Gerotranscendenceteorin. / Research shows that many nursing home residents are disappointed with their level of social interaction and activity. Care of older people is argued to be underpinned by national core values such as supporting dignity and well-being, but it is not clear how such values influence nursing home staff practices or the social activities provided. Our study addressed this question. Five nursing homes, representing both private and public care providers, were sampled from two different municipalities. Semi-structured interviews were carried out with the homes’ respective heads of unit, transcribed, and thematically analysed. Our results indicate that the national values for care of older people were interpreted uniquely within each home. All heads of units emphasised the importance of person-centred care, yet similar social activities were offered by all homes, with a focus on group activities. We discuss our results with reference to activity theory and gerotranscendence.

Bakgrund: Människan påverkas på ett socialt, mentalt och fysiskt plan av de förändringar åldrandet för med sig. En flytt till äldreboende kan bli aktuell när omvårdnadsbehoven blir för omfattande. Inom vården används husdjur på olika sätt. Dock finns en stor variation för hur mycket husdjur används på äldreboenden.Syfte: Syftet med litteraturstudien är att sammanställa resultat av husdjursinterventioner på personer som bor på äldreboende. Vidare är syftet att beskriva undersökningsgruppen i de inkluderade artiklarna.Metod: Föreliggande studie är en litteraturstudie som baserats på 15 kvantitativa vetenskapliga artiklar. Artikelsökning har genomförts i databaserna Cinahl och PubMed.Huvudresultat: Husdjursinterventioner på äldreboenden har visat sig påverka flera faktorer så som social interaktion, beteendeförändringar samt psykisk hälsa. Efter interventionerna ökade social interaktion mellan deltagare, personal och djur samt minskade känslor av ensamhet. Störst ökning av social interaktion påvisades vid stimuli av levande djur jämfört med leksaksdjur. Beteendeförändringar som aggressivitet, vandringsbeteende, rastlöst beteende, avvikande beteende, ovilja att samarbeta och sömnstörningar minskade efter interventionerna, men i flera fall är dock effekten kortvarig. Även förändringar i beteenden kring måltidssituationen har påvisats. Den psykiska hälsan förbättrades efter interventionerna genom minskning av depressiva symtom, ångest, tvångshandlingar, somatisering, förbättrad kognitiv förmåga, bättre humör, bättre upplevd livskvalitet samt autonomi.Slutsats: Resultatet påvisar att husdjursinterventioner har positiva effekter och främjar hälsan för personer som bor på äldreboenden och kan användas som ett komplement till övriga omvårdnadsåtgärder. / Background: Humans are affected on a social, mental and physical way by the changes that come with aging. A move to a nursing home can be necessary when the need of care becomes too substantial. Pets are used in different ways in health care. However, there is a great variety in what extent pets are used in nursing homes.Aim: The purpose of this study is to compile the results of pet interventions on residents living in nursing homes. A further purpose is to describe the study group of the included articles.Method: The present study is a literature review based on 15 quantitative scientific articles. The literature research was executed in the databases Cinahl and PubMed.Main result: Pet interventions in nursing homes have been shown to effect several factors such as social interaction, changes in behaviour and mental health. After the interventions social interaction increased between participants, staff, pets and decreased feelings of loneliness. The greatest increase in social interaction was shown with stimuli by a living pet compared to toypets. Behavioural changes such as agitation, wandering, restlessnes, diverge behaviour, uncoorporative behaviour and sleep disorder decreased after the interventions, but in several cases the duration of the effects was short. Effects have also been shown on behaviours during mealtime. Mental health improved after the interventions by decreasing depressive symptoms, anxiety, compulsive actions, somatisation, improved cognitive function, better mood, better perceieved quality of live and autonomy.Conclusion: The result demonstrates that pet interventions have positive effects and promotes health for residents living in nursing homes and can be used as a complement to other actions of nursing.

Background: Current palliative care recommendations stress the right to care according to palliative principles at the end of life for all people in need thereof, regardless of care place and including those who are old. The international literature indicates that residents in nursing homes often do not have access to palliative care competence. Accordingly, insufficient management and lack of communication about end-of-life issues have been reported. There is a scarcity of robust Swedish studies about the quality of care at the end of life in nursing homes. Aim: To explore the care being provided in the final week of life of older people in nursing homes. Method: The study used data from the Swedish Register of Palliative Care, of all registered individuals aged 60 and older, who died in nursing homes 2011 and 2012. Variables pertaining to monitoring and treatment of symptoms, end-of-life discussions, and circumstances around death, and individual characteristics of the deceased individuals, were explored with descriptive statistics. Results: The most common underlying causes of death were circulatory diseases (42.2%) and dementia (22.7%). The most prevalent symptom was pain (58.7%), followed by rattles (42.4%), anxiety (33.0%), confusion (21.8%), shortness of breath (14.0%) and nausea (11.1%). Pain was the symptom with the highest degree of total relief (46.3%), whereas shortness of breath and confusion were totally relieved in 6.1% and 4.3% of all individuals, respectively. The use of valid instruments for symptom assessments was reported for pain in 12.3% and 7.8% for other symptoms. The most prevalent individual prescriptions for injection PRN were for pain treatment (79.5%) and rattles (72.8%). End-of-life discussions were performed with 27.3% of all the deceased individuals, and with 53.9% of their relatives. Of all individuals, 82.1% had someone present at death, and 15.8% died alone. Of the all nursing home resident deaths recorded, 45.3% died in their preferred place. Conclusion: There were large variations in the degree of relief from the different symptoms in the final week of life. Pain was the most prevalent symptom, and was also the symptom with the highest proportion of total/partial relief. Other symptoms were less prevalent but also less well relieved. The results indicate a need for improvements in palliative care in nursing home settings, focusing management of distressing symptoms and end-of-life discussions. / Bakgrund: Målet om rätt till palliativ vård för alla som behöver, oavsett vårdplats och inkluderande äldre personer. Äldre individer har ofta multisjuklighet, inklusive kognitiv svikt som ställer särskilda krav på kompetens under livets sista tid. Internationella studier indikerar dock att personer som dör på vård- och omsorgsboenden ofta inte får tillgång till palliativ kompetens, med till exempel inadekvat symtomlindring och bristande kommunikation om döden. Robusta svenska studier om innehållet i vården i livets slutskede för personer på vård-och omsorgsboenden saknas. Syfte: Att beskriva vården under den sista levnadsveckan, för äldre personer på vård-och omsorgsboenden. Metod: Studien baserades på data från Svenska Palliativregistret av alla registrerade individer > 60 år som avlidit inom vård- och omsorgsboenden 2011 och 2012. Variabler relaterade till symtom, symtomkontroll, brytpunktssamtal och omständigheter kring döden samt individuella karaktärsdata utforskades med deskriptiv statistik. Resultat: Vanligaste underliggande dödsorsak var cirkulatoriska sjukdomar (42.2%) och demenssjukdomar (22.7%). Mest förekommande symtomet var smärta (58.7%) följt av rosslighet (42.4%), ångest (33.0%), förvirring (21.8%), andfåddhet (14.0%) och illamående (11.1%). Symtomet som lindrades till största del var snärta som helt lindrades för (46.3%) medan andfåddhet och förvirring lindrades helt hos 6.1% respektive 4.3% av individerna. Validerat skattningsinstrument användes för smärta i 12.3% av fallen och i 7.8% för andra symtom. Vanligast förekommande individuella vid behovsordinationen för injektion var för behandling av smärta (79.5%) och mot rosslighet (72.8%).Brytpunktsamtal genomfördes med 27.3% av alla individer och med 53.9% av alla närstående. Önskad dödsplats uppfylldes hos 45.3% av individerna. Av alla individer hade 82.1% någon, i registret valbar, hos sig vid dödsögonblicket och i (15.8%) dog individen ensam. Slutsats: Det fanns stora variationer i graden av lindring för symtom under sista levnadsveckan. Smärta var vanligast förekommande och även det symtom som till högst grad lindrades helt eller delvis. Andra symtom förekom mer sällan men lindrades även till lägre grad. Resultaten indikerar ett behov av förbättring inom den palliativa vården inom vård- och äldreboenden, fokuserat mot hantering av besvärliga symtom samt brytpunktssamtal.

Purpose: The purpose of this study is to understand how elderly peoples` right to participate is revealed in care plans and through contact persons in Swedish community nursing homes in order to shed light on and participate in creating knowledge concerning the phenomena participation and care plans.  Method: A qualitative approach was used in this study with semi-structured interviews and document analysis as a base. In order to gain empirical data six contact persons from two different nursing homes in the same community were interviewed and eight care plans examined. Theory: The theoretical points used to understand the empirical data were Foucaults` theory about power and different theoretical phrases related to power as following: Professional power, relatives` power, client power and resource power. Results: The results show that there is a gap between how elderly peoples` wishes concerning care planning are documented in care plans and expressed by contact persons. Elderly peoples´ possibilities to participate in care planning depend on a variety of aspects like their will and ability to communicate, economic situation, relatives` involvement, time, care plans, amount of ordinary staff and staffs` strategies to explore elderly peoples` wishes in order to allow them to participate in establishing their care plan.

Bakgrund. Sjuksköterskan/specialistsjuksköterskan har som ansvar att omvårdnaden bygger på forskningsresultat och beprövad erfarenhet. Ett antal studier visar att det är gynnande för patienten när forskningsresultat används i omvårdnaden. Sjuksköterskorna har dock svårigheter med att använda forskningsresultat även om de inser vikten av användandet. Syfte. Att se vilka hinder och möjligheter det finns för sjuksköterskor, arbetande på särskilda boenden för äldre, att använda forskningsresultat i sitt arbete. Metod. Beskrivande och jämförande design med kvantitativ ansats. Huvudresultat. Denna studie visar att det största hindret, för sjuksköterskor arbetande på SÄBO, i användningen av forskningsresultat är tidsbrist. De minsta hindren var att sjuksköterskan anser att forskning är relevant för deras arbete och att sjuksköterskorna ser värdet som forskningen har för den kliniska verksamheten. En signifikant skillnad kan ses beroende av ålder hur stora hinder man upplever i användandet av forskningsresultat, där yngre sjuksköterskor skattar högre hinder. Underlättande faktorer var en intresserad och positiv ledning, kollegor att diskutera forskning med samt att forskningsartiklar ska vara tydliga och enkla att förstå. Slutsats. För att ge sjuksköterskor större möjlighet till att använda av forskningsresultat i sitt arbete bör det ges tid till dem att göra detta. / Background. The nurse/specialist nurse has the responsibility that nursing is based on research results and proven experience. A number of studies show that it is beneficial for the patient when research results are used in nursing care. Nurses, however, have difficulty using research results even if they realize the importance of the use. Aim. To see what obstacles and opportunities there are for nurses, working in nursing homes, to use research results in their work. Method. Descriptive and comparative design with quantitative approach. Main results. This study shows that the biggest obstacle, for nurses working in nursing homes, in the use of research results, is the lack of time. The smallest obstacles were that the nurse considers that research is relevant to their work and that nurses see the value of research for the clinical activity. A significant difference can be seen depending on age how big barriers you experience in the use of research results, where younger nurses estimate higher barriers. Facilitating factors were an interested and positive management, colleagues to discuss research, and that research articles should be clear and easy to understand. Conclusion. In order to give nurses greater opportunity to use research results in their work, they should be given time to do this.

As the population of senior citizens increase, various housing options are required for an increasing competitive environment within elderly care. This study addresses the concept of profile housing for the elderly by outlining its definition and providing options for the different kinds of housing options available within the municipalities of Stockholm and Solna. The study reveals that these locations have different definitions of what constitutes a profile home. Based on this, should one assume there are further definitions to cover additional municipalities?      This study also touches upon how a group of senior citizens would perceive their living conditions if relocated into such housing. Members of the group have also expressed that they would like to go about their daily activities as they have prior to being relocated. They want health professionals to enable and encourage participation in various daily activities.

Bakgrund Personcentrerad vård innebär att vården utgår från patienten och dess upplevelse av ohälsa och sjukdom, sociala sammanhang och dess närstående. Personcentrerad vård utgår från tre nyckelbegrepp som Centrum för personcentrerad vård arbetat fram och dessa är; partnerskap, patientberättelsen och dokumentation. Syfte Att beskriva sjuksköterskors erfarenheter av hur de arbetar med personcentrerad vård; partnerskap, patientberättelsen och dokumentation, på somatiska avdelningar på vård- och omsorgsboenden.  Metod Deskriptiv studie med kvalitativ deduktiv ansats. Studien baserades på åtta semistrukturerade intervjuer som analyserades med kvalitativ innehållsanalys. Resultat Analysen resulterade i ett tema; Samtal som redskap för att praktisera personcentrerad vård. Tre kategorier var förutbestämda och sju subkategorier identifierades: Partnerskap; ta del av den äldres kunskap, ta del av anhörigas kunskap, omvårdnadspersonalens kunskap, sjuksköterskans kunskap, Patientberättelsen och Dokumentation; dokumentation i levnadsberättelsen, dokumentation i genomförandeplan och dokumentation i dokumentationssystemet utifrån personcentrerad vård.  Konklusion Samtalet är en av sjuksköterskans viktigaste redskap för att praktisera personcentrerad vård. Genom samtal bygger sjuksköterskan en relation till den äldre och utvecklar ett partnerskap. Samtal är även en förutsättning för att skapa relation till anhöriga samt för ett välfungerande teamarbete. Dock visade det sig att sjuksköterskorna upplevde att de arbetade för långt från den äldre personen och att de inte alltid hade tid för fördjupade samtal. / Background In person-centered care the patient and his/her experience of illness, disease, social content and close relationships is central. Person-centered care emanates from three keywords developed at University of Gothenburg Centre for Person-Centered Care (GPCC): Partnership, the patient narrative and documentation. Purpose To describe the experiences nurses have from person-centered care and how they work with partnership, the patient narrative and documentation at general units in nursing homes. Method Descriptive study conducted with a qualitative deductive approach. The study was based upon eight semi-structured interviews and data was analyzed using qualitative content analysis. Results One theme was identified: The communicative conversation used as a tool in order to perform person-centered care. Three categories were predetermined and the analysis resulted in seven subcategories: Partnership; to utilize the patient´s knowledge, to utilize the knowledge held by relatives, caregivers and the nurse, The patient narrative and Documentation; documentation of the story of the patient´s life, documentation in individualized care-plans and documentation in the system of documentation from a personal- centered perspective. Conclusion The communicative conversation was essential in order to perform person-centered care. Within this conversation, the nurse will be able to develop a relationship with the patient and from that relationship a partnership will evolve. In addition, a communicative conversation is of crucial importance in order to evolve relationships with relatives and to maintain functional cooperation. However, it turned out that the nurses experienced that they worked too far from the older person and that they did not always have time for in-depth conversations.

Este é um estudo sobre regras temporais às quais residentes em instituições asilares são submetidos e os possíveis impactos que a homogeneização de horários e duração das atividades podem exercer sobre seus ritmos biológicos. A homogeneização dos tempos sociais pode causar dessincronização temporal interna, o que interfere nos processos corporais causando dessincronização temporal externa, isto é: desajustes entre eventos ambientais e fisiológicos, criando problemas nos ciclos de vigília/sono e humor, entre outros colaborando para o declínio do desempenho cognitivo. Em um ambiente asilar, preferências pessoais relacionadas à fixação de horários e duração das atividades em geral, não são consideradas. Entendo que pelo exercício do poder e pelo disciplinamento ao longo do curso de vida, os velhos que vivem em instituições tendem a naturalizar as normas estabelecidas; submissão essa que entendo ocorrer com as minorias em geral. Considero importante reconhecer as vontades dessas pessoas, atentando-se para suas identidades como pessoas e não apenas como corpos para serem cuidados, independentes dos sujeitos que os possuem. Localizo este trabalho no campo dos Estudos Culturais seguindo uma das suas tendências que é a do estudo etnográfico de populações envolvendo questões de gênero, raça e etnia, principalmente se tratando de uma minoria. Questões de corpo, solidão e indivíduo foram consideradas, juntamente com a cronobiologia, estudo dos ritmos biológicos, sendo o mais conhecido o ritmo circadiano. Participaram desta pesquisa 29 residentes, sendo 21 mulheres e 8 homens, com idades entre 75 e 99 anos de seis unidades de duas instituições para idosos, na zona leste e na zona sul do município de São Paulo-SP. A primeira técnica aplicada foi a observação selvagem, que consiste em observar situações, buscando ao máximo manter neutralidade em relação ao ambiente, o que já permitiu observar resistência aos horários de refeições, cochilos diurnos, mau humor, estado geral de apatia e tempo na cama superior a 13 horas. Instrumentos e técnicas: a) Questionário sociodemográfico (dados pessoais, satisfação geral com a vida e escala de depressão geriátrica); b) Diário de sono; c) Questionário de determinação de cronotipo matutinidade/vespertinidade); d) Entrevista gravada; e) Técnica etnográfica da observação participante; f) Análises estatísticas; g) Análise do discurso para as entrevistas gravadas e dados de observação. Resultados e conclusões: os residentes não têm críticas sobre a rotina e horários e não proporiam mudanças; a maioria apresentou tendência à distimia e à depressão maior; mesmo os residentes que têm preferências vespertinas dormem cedo; a maioria relatou não ter apetite; apenas 10% residem por escolha própria; a desorganização temporal nos idosos foi parcialmente comprovada. Em função dos discursos analisados concluiu-se que as regras temporais são um dos desafios, dada a identificação de inúmeros fatores que influenciam negativamente a vida em uma instituição asilar / This is a study of temporal rules that residents in nursing homes are subjected and the potential impacts on their biological rhythms that the homogenization of time and duration of the activities may cause. The homogenization of social time can lead to internal temporal desynchronization, which interferes with bodily processes causing external temporal desynchronization, this means imbalances between environmental and physiological events which may produce problems in their sleep/wake cycles, mood, among others, contributing to the decline of cognitive performance. Personal preferences of timing and duration of activities in nursing homes are not considered, in general. I understand that old people living in institutions tend to naturalize the established norms because of the exercise of power and discipline throughout their course of life, submission to the rules usually found in minorities. I consider important to recognize the choices of these people, attending to their identities as individuals and not just as bodies to be maintained, independent of the individuals who own them. This work is in the field of Cultural Studies following one of its trends that is the ethnographic study of populations involving gender, race and ethnicity, especially when dealing with a minority. Body issues, loneliness and the individual will be considered in the field of chronobiology - the study of biological rhythms, as the circadian rhythm, present in almost all biological phenomena. Participated in this study 29 residents, 21 women and 8 men, aged between 75 and 99 years from six units of two nursing homes in the east and in the south of São Paulo-SP. The first technique applied was the Wild Observation, which consists in the observation trying to maintain neutrality towards the environment, which allowed us to witness conflicts with meal times; daytime naps; bad mood; general state of apathy; longer than 13 hours in bed. Instruments and techniques were applied: a) Sociodemographic; b) Sleep Diary; c) Chronotype; d) Recorded interview; e) Participant Observation; f) Statistics Analysis; g) Discourse Analysis for the recorded interviews and observation data. The main results and conclusions include the absence of criticisms concerning daily routines without proposition of changes; signs of depression and dystimia were observed in the majority of the population studied, evening type individuals going to bed early, generalized loss of appetite, and a minority of 10% chose to live in the institution; temporal disorganization in the elderly was partially confirmed. According to the speech analyses it was concluded that the temporal rules are a challenge and there are several factors that negatively influencing life in a nursing home

En viktig del i det förebyggande arbetet för att bibehålla hälsa, är att förhindra vårdrelaterade infektioner. Särskilt boende för äldre utgör en arena för vård, omsorg och hälsa. Med vårdrelaterade infektioner menas en infektion som uppkommer hos en person i vård eller omsorg till följd av en åtgärd personen erhållit. En central strategi för att bibehålla hälsa och främja folkhälsa är att förebygga infektionssjukdomar i vårdinrättningarna. Faktorer som påverkar personalens följsamhet till hygienrutinerna i kommunal vård och omsorg är resurser, ledning, personal och externa faktorer. Syftet med studien var att beskriva vad vårdhygien på ett särskilt boende för äldre innebar utifrån ett chefsperspektiv. Metoden var en kvalitativ intervjustudie. Sju chefer på särskilt boende intervjuades med semistrukturerade frågor. Resultatet analyserades med en kvalitativ innehållsanalys. Resultat och huvudfynd i studien visade att chefer inom särskilt boende för äldre var mycket medvetna om att vårdhygien har stor relevans för att minimera och bryta smittspridning. De belyste även behov av att arbeta mer centrerat och strukturerat med den vårdhygieniska frågan. Faktorer som kunskap, lokaler, inställning, attityder samt ekonomi är områden som ibland brister och kunde arbetas mer med. Slutsatsen av denna studie visar att chefer inom särskilt boende för äldre är mycket medvetna om att vårdhygien har stor relevans för att minimera och bryta smittspridning. Det finns även behov av att arbeta mer centrerat och strukturerat med den vårdhygieniska frågan. Svårigheter med det vårdhygieniska arbete kan grunda sig i att förutsättningar som kunskap, lokaler, inställning, attityder och ekonomi ibland brister. / An important part of preventive work to maintain health is to prevent healthcare-associated infections. Nursing home for the elderly is an arena for health and care. Healthcare-associated infections refer to infections among persons in care as an outcome of an action of care. A central strategy for maintaining health and promoting public health is to prevent infectious diseases in the healthcare facilities. Factors that affect the adherence of staff to the hygiene routines in municipal care are resources, management, personnel and external factors. Aim of the study was to describe what infection control in a nursing home for the elderly meant from a managerial perspective. The method was a qualitative interview study. Seven managers for nursing homes were interviewed with semi-structured questions. The result was analyzed with a qualitative content analysis. Results and main findings in the study showed that managers in nursing home for the elderly were very aware of that work with infection control is of great relevance to minimize and break the spread of infection. They also highlighted needs such as working more centrally and structured with infection control and hygiene issues. Factors such as knowledge, premises, attitude, and finances sometimes fail and could be more elaborated in work. The conclusion of this study shows that managers in special housing for the elderly are very aware that health care is of great relevance to minimize and break the spread of infection. There is also a need to work more centrally and structured with the health-hygienic issue. Identified difficulties with the health-hygienic work since conditions such as knowledge, premises, attitudes, attitudes and finances sometimes fail.