Bakgrund: För ungefär 35 år sedan uppmärksammades HIV som ett sjukdomstillstånd bland människor. Sedan dess har infektionen skördat många liv främst i Afrika och har också kommit att förknippas med homosexuella personer som dock utgör en minoritet av alla smittade. Globala insatser försöker minska dessa dödsantal och i Sverige har kunskapen och attityder kring HIV förbättrats under de senaste årtiondena. Trots detta förekommer det fortfarande brister i kunskap om HIV men också i attityder mot personer som är smittade. Vård skall bedrivas med respekt oavsett sjukdom och betydelsen av kommunikation är stor för att kunna bedriva personcentrerad vård och för att ha ett gott vårdklimat. Syfte: Syftet var att beskriva hur patienter med HIV upplever bemötande inom vården. Metod: En litteraturöversikt har genomförts vilket innebär att befintlig kunskap från elva vetenskapliga artiklar har analyserats och sammanställts inom ett specifikt område. Resultat: Översiktens resultat presenteras i två huvudteman med fyra respektive sex underteman. Det första huvudtemat positiva upplevelser av bemötandet i vården har följande underteman: relationsfrämjande värden, vårdgivarens stöd och support, den goda vårdrelationen samt närhet – ett tecken på acceptans. Det andra huvudtemat negativa upplevelser av bemötandet i vården har följande underteman: särskiljande bemötande på grund av diagnos, vårdgivarens försiktighetsåtgärder, olämpligt bemötande, en otillräcklig vårdrelation, vårdgivares affektiva tillstånd och agerande samt sekretessbrott. Diskussion: Det som framkom i resultatet har diskuterats utifrån kunskap om HIV från sjuksköterskor och sjuksköterskestudenter. Här belyses vikten av adekvat kunskap om HIV men också om kommunikation inom vården och hur denna kunskap bör tillhandahållas. Detta har diskuterats utifrån Joyce Travelbees omvårdnadsteori. / Background: HIV-infection among humans received attention throughout the world 35 years ago from the dramatic increase in deaths. The deadly virus has spread globally with intensity in the African continent. The virus has been somewhat falsely characterized as the “homosexual disease” even though this group represents a minority of all people living with HIV. Global programs are taking action to decrease the amount of deaths and the knowledge and attitude towards the virus has improved in Sweden through the last decades. Despite this, there are still dramatic misunderstandings in knowledge about HIV and attitudes towards HIV-infected people. Care should be given with respect no matter diagnosis, and adequate communication is of vital importance to be able to perform individualized care in a proper functioning healthcare setting. Aim: How HIV-infected patients experience interaction with healthcare professionals. Method: A literature review was conducted to analyze and compile data of existing knowledge from eleven scientific articles within a specific area of study. Results: The results of the review are presented in two main themes. The first main theme is positive experiences of interactions within healthcare that includes following sub themes: relationship-building values, the support given by caregivers, a positive professional-patient relation and closeness – a sign of acceptance. The second main theme is negative experiences of interactions within healthcare which includes following sub themes: differential treatment because of HIV, precautions exceeded by caregivers, inappropriate encounters, emotions and actions exceeded by caregivers and confidentiality breaches. These themes describe how patients experienced encounters within healthcare settings negatively. Discussion: The result findings are discussed from nurses and nursing students perspectives on knowledge about HIV. The importance of both knowledge about HIV and communication is highlighted, and how healthcare professionals should acquire these understandings. This has been discussed using Joyce Travelbee´s nursing theory.

The purposeof the study was to investigate whether occupational therapists find that therapy dogs can affect the relationship with the client and client´s participation in activity. The methodused was a qualitative study with ten participants who were contacted via recommendations and via the social network Facebook. The questions concerned the occupational therapists' experience of working with therapy dogs and their experiences of whether the therapy dog ​​can be a tool to help create relationship with the client and motivate for activity. The resultshowed that the experience was predominantly positive and that the therapy dog ​​made the client contact stronger. The occupational therapists experienced that they could go further in their interventions with the help of the dog and that the clients opened up more and were more motivated to participate in activities when the dog was present. It also showed that education, planning, goal setting and journaling were important to demonstrate the effect of therapy dogs. Conclusion:The result showed positive situations in which the therapy dog ​​was an aid for the occupational therapists' success in the intervention. The study showed that contact with the client was strengthened with the help of the therapy dog ​​and that the motivation to participate in activities increased. / Syftet med studien var att undersöka omarbetsterapeuter upplever att terapihundarkan påverkarelationen till klienten samtklientensdelaktighet i aktivitet. Metodensom användes var en kvalitativ studie med tiodeltagare som kontaktades via rekommendationer och via det sociala nätverket Facebook. Frågorna berörde arbetsterapeuternas upplevelse kring att arbeta med terapihund och deras erfarenheter om huruvida terapihunden kan vara ett hjälpmedel för att hjälpa till att skapa relation till klienten och motivera till aktivitet. Resultatetvisade att erfarenheterna var övervägande positiva och att terapihunden gjorde att klientkontakten blev starkare. Arbetsterapeuterna upplevde att de kunde komma längre i sina interventioner med hjälp av hunden och att klienterna öppnade upp sig mer och var mer motiverade till att delta i aktiviteter närhunden var närvarande.Det visade också att utbildning, planering, målsättning och journalföring var viktigt för att visa på terapihundarnas effekt.Slutsats: Resultatet visade positiva situationer där terapihunden varit ett hjälpmedel för arbetsterapeuternas framgång i interventionen. Studien visade att kontakten till klienten stärktes med hjälp av terapihunden och att motivationen att delta i aktiviteter ökade

Fibromyalgi (FMS) är ett syndrom som främst karaktäriseras av kroniska smärtor i olika delar av kroppen. Patienter med FMS upplever ofta skepsis och misstro i mötet med vården på grund av att deras symptom är osynliga. Samtidigt kan det vara svårt för sjuksköterskor och övrig vårdpersonal att veta hur de ska förhålla sig till en sjukdom som inte uppvisar några kliniska fynd och vars etiologi fortfarande är relativt okänd. Dessa omständigheter gör vårdrelationen komplex. Syftet med denna studie är därför att utforska hur vårdrelationen upplevs mellan patienter med FMS och sjuksköterskor. 11 artiklar har analyserats, ur vilka ett huvudtema, fyra teman och två subteman identifierades. Resultatet visar att brist på tid, kunskap och förståelse resulterar i en problematisk vårdrelation. Betydelsen av att vårda dessa patienter i ett multiprofessionellt team framgår även. I diskussionen utvecklas på vilka sätt patienter med FMS och sjuksköterskor upplever vårdrelationen olika. Sjuksköterskornas känslor av maktlöshet kan från patientens sida istället uppfattas som ointresse och brist på engagemang, vilket kan medföra att patienterna tar med sig negativa känslor in i nya vårdmöten.

A presente pesquisa é um estudo qualitativo sobre a relação médico-paciente em pediatria, especificamente da relação do pediatra com a criança portadora de anomalia congênita e sua família. O estudo decorre da experiência em escolas especiais, na condição de médico pediatra. O pressuposto básico desta pesquisa é que existe uma dificuldade do médico em se relacionar com estes pacientes e sua família, devido a sua formação médica “deficiente”. Os objetivos da pesquisa foram: 1) identificar sentimentos e atitudes do pediatra no seu relacionamento com crianças com anomalias congênitas e seus familiares e 2) identificar as dificuldades de relacionamento do pediatra com estas famílias. A metodologia utilizada é uma “variante da pesquisa qualitativa”, que trabalha o conceito de representações sociais, segundo as correntes de pensamento mais importantes na área da saúde, aliada ao método psicodramático na coleta e análise dos dados. Foram entrevistados 10 (dez) pediatras, utilizando-se um roteiro de entrevista do tipo não-estruturada. As entrevistas foram gravadas em fita cassete e a análise dos dados evidenciou a “deficiência” da formação médica no ensino da relação médico-paciente. Além disso, emitimos a tese de que esta dificuldade está ligada com a imagem de onipotência, tanto do médico como de outros profissionais de saúde, fruto de sua formação universitária. Quanto à prática médica pôde-se identificar uma atividade intensa em número de horas por dia de trabalho, que prejudica a formação continuada formal e informal, a reflexão sobre esta prática e a atenção dispensada a cada paciente, caracterizando o que chamamos de “ativismo”. Também pudemos perceber diferenças na relação médico paciente quanto à classe social do paciente. Foram identificados sentimentos de choque emocional, depressão e impotência nos médicos frente à deficiência, com destaque para a ansiedade no momento de falar com os pais sobre a deficiência de seus filhos. Quanto ao momento especifico de dar a notícia aos pais sobre o nascimento de um bebê com anomalia congênita, foram identificadas práticas consideradas inadequadas pela maioria dos estudiosos do assunto. Com a intenção de "proteger a mãe", quase todos os entrevistados revelaram a prática de contar a notícia primeiro ao pai, sem a presença da mãe, sedando-a logo após o parto. Outra prática identificada foi a de criar expectativa sobre a saúde do bebê para "preparar" a mãe e os familiares para receberem a notícia. Finalmente, é sugerido que a formação médica passe a discutir o relacionamento com famílias de crianças com deficiência e a criação de equipes multiprofissionais em maternidades e Unidades de Terapia Intensiva, com a função de transmitir informações aos pais e familiares, nos casos de anomalia congênita, estados graves de saúde com possibilidade de seqüelas ou morte de bebês. / The present investigation is a qualitative study of the doctor-patient relationship in pediatrics, specifically of the relationship between pediatrician and children with congenital anomalies and their families. The study is based on the author’s experience in special schools as a pediatrician. The basic assumption of this study is that the physician has difficulty in relating to these patients and their families due to his “disabled” medical training. The objectives of the study were: 1) to identify the feelings and attitudes of the pediatrician in his relationship with children with congenital anomalies and their relatives, and 2) to identify the difficulties experienced by the pediatrician in relating to this families. The methodology used was a “variant of qualitative research” which explores the concept of social representations according to the most important currents of thought in the health area, allied to the psychodrama method for data collection and analysis. Ten pediatricians were interviewed using a nonstructured questionnaire. The interviews were recorded on tape and data analysis demonstrated the “disablement” of medical training in terms of teaching about the doctor-patient relationship. In addition, the author proposes the thesis that this difficulty is linked to the image of omnipotence both of the doctor and of other health professionals, created by their university education. With respect to medical practice, intense activity was identified in terms of number of work hours per day, which impairs continuing formal and informal education, the reflection about this practice and the attention given to each patient, characterizing what we call “activism”. It was also possible to perceive differences in the doctor-patient relationship in terms of the social class of the patient. Feelings of emotional shock, depression and impotence were detected in physicians facing these disablements, with emphasis on the anxiety they feel when they must talk to the parents about the disablement of their children. As to the specific time when the news should be broken to parents about the birth of a baby with a congenital anomaly, the practices identified are considered inadequate by most of those who study this subject. With the intention of “protecting the mother”, almost all the doctors interviewed revealed the practice of first disclosing the news to the father without the presence of the mother, whom they submit to sedation soon after delivery. Another practice identified was to create expectations about the health of the baby in order to “prepare” the mother and the other relatives to receive the news. Finally, the author suggests that medical education should start to involve the discussion of the relationship with the families of disabled children and the creation of multiprofessional teams in maternities and in Intensive Care Units in order to transmit information to the parents and relatives in cases of congenital anomalies or of serious health conditions involving the possibility of sequels or of infant death.

A presente pesquisa é um estudo qualitativo sobre a relação médico-paciente em pediatria, especificamente da relação do pediatra com a criança portadora de anomalia congênita e sua família. O estudo decorre da experiência em escolas especiais, na condição de médico pediatra. O pressuposto básico desta pesquisa é que existe uma dificuldade do médico em se relacionar com estes pacientes e sua família, devido a sua formação médica “deficiente". Os objetivos da pesquisa foram: 1) identificar sentimentos e atitudes do pediatra no seu relacionamento com crianças com anomalias congênitas e seus familiares e 2) identificar as dificuldades de relacionamento do pediatra com estas famílias. A metodologia utilizada é uma “variante da pesquisa qualitativa", que trabalha o conceito de representações sociais, segundo as correntes de pensamento mais importantes na área da saúde, aliada ao método psicodramático na coleta e análise dos dados. Foram entrevistados 10 (dez) pediatras, utilizando-se um roteiro de entrevista do tipo não-estruturada. As entrevistas foram gravadas em fita cassete e a análise dos dados evidenciou a “deficiência" da formação médica no ensino da relação médico-paciente. Além disso, emitimos a tese de que esta dificuldade está ligada com a imagem de onipotência, tanto do médico como de outros profissionais de saúde, fruto de sua formação universitária. Quanto à prática médica pôde-se identificar uma atividade intensa em número de horas por dia de trabalho, que prejudica a formação continuada formal e informal, a reflexão sobre esta prática e a atenção dispensada a cada paciente, caracterizando o que chamamos de “ativismo". Também pudemos perceber diferenças na relação médico paciente quanto à classe social do paciente. Foram identificados sentimentos de choque emocional, depressão e impotência nos médicos frente à deficiência, com destaque para a ansiedade no momento de falar com os pais sobre a deficiência de seus filhos. Quanto ao momento especifico de dar a notícia aos pais sobre o nascimento de um bebê com anomalia congênita, foram identificadas práticas consideradas inadequadas pela maioria dos estudiosos do assunto. Com a intenção de "proteger a mãe", quase todos os entrevistados revelaram a prática de contar a notícia primeiro ao pai, sem a presença da mãe, sedando-a logo após o parto. Outra prática identificada foi a de criar expectativa sobre a saúde do bebê para "preparar" a mãe e os familiares para receberem a notícia. Finalmente, é sugerido que a formação médica passe a discutir o relacionamento com famílias de crianças com deficiência e a criação de equipes multiprofissionais em maternidades e Unidades de Terapia Intensiva, com a função de transmitir informações aos pais e familiares, nos casos de anomalia congênita, estados graves de saúde com possibilidade de seqüelas ou morte de bebês. / The present investigation is a qualitative study of the doctor-patient relationship in pediatrics, specifically of the relationship between pediatrician and children with congenital anomalies and their families. The study is based on the author’s experience in special schools as a pediatrician. The basic assumption of this study is that the physician has difficulty in relating to these patients and their families due to his “disabled" medical training. The objectives of the study were: 1) to identify the feelings and attitudes of the pediatrician in his relationship with children with congenital anomalies and their relatives, and 2) to identify the difficulties experienced by the pediatrician in relating to this families. The methodology used was a “variant of qualitative research" which explores the concept of social representations according to the most important currents of thought in the health area, allied to the psychodrama method for data collection and analysis. Ten pediatricians were interviewed using a nonstructured questionnaire. The interviews were recorded on tape and data analysis demonstrated the “disablement" of medical training in terms of teaching about the doctor-patient relationship. In addition, the author proposes the thesis that this difficulty is linked to the image of omnipotence both of the doctor and of other health professionals, created by their university education. With respect to medical practice, intense activity was identified in terms of number of work hours per day, which impairs continuing formal and informal education, the reflection about this practice and the attention given to each patient, characterizing what we call “activism". It was also possible to perceive differences in the doctor-patient relationship in terms of the social class of the patient. Feelings of emotional shock, depression and impotence were detected in physicians facing these disablements, with emphasis on the anxiety they feel when they must talk to the parents about the disablement of their children. As to the specific time when the news should be broken to parents about the birth of a baby with a congenital anomaly, the practices identified are considered inadequate by most of those who study this subject. With the intention of “protecting the mother", almost all the doctors interviewed revealed the practice of first disclosing the news to the father without the presence of the mother, whom they submit to sedation soon after delivery. Another practice identified was to create expectations about the health of the baby in order to “prepare" the mother and the other relatives to receive the news. Finally, the author suggests that medical education should start to involve the discussion of the relationship with the families of disabled children and the creation of multiprofessional teams in maternities and in Intensive Care Units in order to transmit information to the parents and relatives in cases of congenital anomalies or of serious health conditions involving the possibility of sequels or of infant death.

This thesis 'The Symphony of Care' consists of four studies focusing on care relationships between patients and professional caregivers. Care relationships are central to the health process and a fundamental element in caregiving. The term care relationship is widely used in caring science but lacks a clear definition, which can create misunderstanding and can constitute an obstacle when attempting to optimize care relationships. The aim of this thesis is to describe the phenomenon of care relationships in order to add to the body of knowledge in caring science.The main research questions are: • What is a care relationship within the caring science field? • How can a care relationship be optimized to improve its caring function, in order to promote health? The ontological foundation of this thesis is caring science. Phenomenology and Lifeworld theory are used as its epistemological bases. Reflective Lifeworld Research is used as a methodological approach. The four studies were conducted in different contexts and cultures- the first two empirical studies were performed in China and the remaining two, a metasynthesis and a secondary analysis, were carried out in a Swedish context. The results show that care relationships are temporary intentional relationships between a person who needs help and a helper. The purpose of this relationship is to support the patient in his/her dynamic health process, which is unique for each person in different times and contexts. Care relationships are fragile because the patient is vulnerable and the demand on the helper is great. It is an inter-human relationship between equals, which can at the same time be an asymmetric relationship due to the professionalism with the caregiver and the vulnerability with the patient. A care relationship is not independent, but is affected by internal factors such as the two individuals' lifeworlds and external factors such as health policies, organization, economics, health culture and environment. To optimize the effectiveness of caring, the relationship and its surrounding need to be in harmony. The view of care relationships should be broadened to include the external resources in order to optimize their caring potential.

Objective: To explore differences between conventional medicine (COM) and complementary and alternative medicine (CAM) regarding the attitude toward and the perceived use of shared decisionmaking (SDM) from the health professional perspective. Methods: Thirty guideline-based interviews with German GPs and nonmedical practitioners were conducted using qualitative analysis for interpretation. Results: The health professional–patient-relationship in CAM differs from that in COM, as SDM is perceived more often. Reasons for this include external context variables (e.g. longer consultation time) and internal provider beliefs (e.g. attitude toward SDM). German health care policy was regarded as one of the most critical factors which affected the relationship between GPs and their patients and their practice of SDM. Conclusion: Differences between COM and CAM regarding the attitude toward and the perceived use of SDM are attributable to diverse concepts of medicine, practice context variables and internal provider factors. Therefore, the perceived feasibility of SDM depends on the complexity of different occupational socialization processes and thus, different value systems between COM and CAM. Practice implications: Implementation barriers such as insufficient communication skills, lacking SDM training or obedient patients should be reduced. Especially in COM, contextual variables such as political restrictions need to be eliminated to successfully implement SDM.

Objective: To explore differences between conventional medicine (COM) and complementary and alternative medicine (CAM) regarding the attitude toward and the perceived use of shared decisionmaking (SDM) from the health professional perspective. Methods: Thirty guideline-based interviews with German GPs and nonmedical practitioners were conducted using qualitative analysis for interpretation. Results: The health professional–patient-relationship in CAM differs from that in COM, as SDM is perceived more often. Reasons for this include external context variables (e.g. longer consultation time) and internal provider beliefs (e.g. attitude toward SDM). German health care policy was regarded as one of the most critical factors which affected the relationship between GPs and their patients and their practice of SDM. Conclusion: Differences between COM and CAM regarding the attitude toward and the perceived use of SDM are attributable to diverse concepts of medicine, practice context variables and internal provider factors. Therefore, the perceived feasibility of SDM depends on the complexity of different occupational socialization processes and thus, different value systems between COM and CAM. Practice implications: Implementation barriers such as insufficient communication skills, lacking SDM training or obedient patients should be reduced. Especially in COM, contextual variables such as political restrictions need to be eliminated to successfully implement SDM.