andersson å. & hansebo g. (2009) Elderly peoples' experience of nursing care after a stroke: from a gender perspective. Journal of Advanced NursingAbstract Title. Elderly peoples' experience of nursing care after a stroke: from a gender perspective. Aim. This paper is a report of a study conducted to explore, from a gender perspective, older people's experiences of nursing care after a stroke. Background. Little attention has been given to gender differences in nursing care. The majority of people who have a stroke are older. Improving knowledge of the gender perspectives of older men and women regarding nursing care after stroke is crucial. Method. This was a qualitative study based on interviews with five women and five men between 66 and 75 years of age, who had received nursing care at a ward for stroke rehabilitation. The data were collected in 2006. Qualitative content analysis of the interviews was carried out. Findings. A main theme and five categories, all common to both men and women, were identified. The main theme, to promote recovery of the body, encompassed the categories. There were, however, gender differences in how the nursing care received was experienced. The ways patients experienced nursing care seemed to be linked with their lives as women and men before they had the stroke. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ. Conclusion. Nurses need to increase their awareness and knowledge concerning the similarities and gender differences in the experiences and needs of older people, both men and women.

The purpose of this study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention on a psychiatric intensive care unit. The intervention aimed to improve nursing care by addressing patient violence from multiple perspectives. During the study, the unit was reorganized toward a higher concentration of severely disturbed patients. The results showed an increased proportion of coercive interventions without a corresponding increase in staff injuries. Use of coercive interventions is discussed in relation to a safe environment for both patients and staff.

Organizational changes are common in elder care today. Such changes affect caregivers, who are essential to providing good quality care. The aim of the present study was to illuminate caregivers' experiences of working in elder care while under threat of organizational change and termination notice. Qualitative content analysis was used to examine interview data from 11 caregivers. Interviews were conducted at three occasions during a two-year period. The findings show a transition in their experiences from 'having a professional identity and self-confidence', to 'being a professional in a threatening situation caused by someone else' and to 'struggling to adapt to a changed working environment as a person and a professional'. The caregivers experienced a loss of pride and satisfaction. Previous literature indicates that this may have consequences for the quality of care and that employees may be at risk of negative health effects. However, the caregivers continued to struggle, doing their best to complete their duties. The study has implications for high-level decision-makers, managers and caregivers in similar work-life situations in that it deals with factors that facilitate or impede similar transitions.

The study in this thesis was conducted as an intervention project in three nursing home wards in Sweden, in a big city as well as in rural areas, one year in each ward. The intervention consisted of supervision for individualised and documented nursing care with a multidimensional assessment instrument, the Resident Assessment Instrument (RAI/MDS), used as a basis. The main aim was to evaluate the intervention in the wards.

Study I aimed at reviewing nursing documentation in the wards before and after the intervention. Quantitative content analysis was used to review the total number of nursing documentation (n = 58 + 57). The greatest change seen after intervention was the writing of care plans for the individual patients. Daily notes increased in length and number but reflected mostly occasional situations, as before. Computer-triggered Resident Assessment Protocol (RAP) items, obtained from the RAI/MDS assessments and regarded as a means of quality assurance, was used to compare items in the nursing care plans. The aim of study II was to compare patients' life stories and current situations as told by carers (n = 30 + 30). Qualitative content analysis was used to disclose changes and to enable descriptions of patterns in the text. After the intervention the patient was more seen as a unique person with resources and abilities despite limitations, and the nurses' awareness of their own professional approach increased. In study III a phenomenological-hermeneutic approach was used to illuminate nurses' video recorded interactions in morning care sessions involving patients, in one ward, suffering from severe dementia. In order to disclose any changes in the nurses' interactions the video recordings were conducted before, during and after the intervention (n = 24). The meaning in the interactions between the nurse and the patient were communicated through the balancing in actions and reactions, verbal- as well as non- verbal, and was about confirmation and the lack of it. This could fluctuate at times and be present within the whole complex of nursing care situations. The intervention contributed to developing a relationship of intersubjectivity and thus a greater emphasis on confirming nursing care. In study IV stimulated recall interviews were used in connection with the video recordings in order to illuminate the significance of nurses' reflections on their interactions with the patients (n = 12). Another aim was to find out if any changes in their reflections took place across the intervention. A phenomenological-hermeneutic approach revealed that nurses improved their ability to verbalise their reflections and to be aware of their own influence on care quality. The meaning in nurses' reflections was about efforts to maintain a sense of dignity for the patients as well as for themselves. In study V the Cognitive Performance Scale (CPS) included in the RAI/MDS was used to demonstrate the cognitive performance in elderly persons on different levels of care (n = 1276). Cognitive impairments in different stages were found for all levels of care investigated. In nurses' views (n = 50) of using the RAI/MDS (V) a majority thought that the instrument could contribute to improved care quality, even if some of them were hesitant. As the instrument made nurses more aware of the need for information, they thought that information as well as knowledge about the patient increased. They stated in their comments that the assessment covered all areas, and that they sought information they had not paid attention to or bothered about before the intervention, and further, that more of the patients' capacity and interests were considered. The importance of continuing education and supervision was confirmed by the study. It seemed as if the supervision and the use of a comprehensive and detailed assessment tool contributed to increased knowledge about the patients and to efforts to see them as real persons even behind a dementia surface.

Handledning kan bidra till att vård och omsorg om den äldre människan ses som en stor och viktig utmaning. Det kan vara ett erbjudande vid rekrytering och ett sätt att bibehålla personal inom vård och omsorg av den äldre människan.

Stimulated recall interviews were used in connection with carers' video-recorded interactions with patients suffering from severe dementia before, during and after a 1-year intervention involving supervision for individualized nursing care. The aim was to illuminate carers' reflections on their everyday life with the patients, and to find out if any changes took place across the intervention. A phenomenological-hermeneutic approach was used in the analysis, which revealed that carers' reflections were focused on the carers themselves, on the patients, on context and on the work itself in the shared everyday life. After repeated stimulated recall interviews, together with supervision every month, an improvement in carers' ability to verbalize their reflections and an awareness and knowledge about their own influence on care quality were seen. The interdependence between carers and patients made it necessary for the carers to cope with many complicated here-and-now situations, and in their reflections the carers kept coming back to their efforts to maintain a sense of dignity for the patients as well as for themselves. Reflection through stimulated recall seems to be an important tool for carers in dementia care to facilitate understanding and to help them learn through lived experience, thus developing their skills in nursing care.

Knowing a patient's life story is important for good nursing care of frail and vulnerable elderly people with cognitive impairments. The aim of the study was to compare patients' life stories and current situations as told by carers before and after 1 year of supervision, in which the Resident Assessment Instrument was used as a basis for individualized nursing care. Qualitative content analysis was used to disclose changes and to enable descriptions of patterns. After the intervention, two overall perspectives emerged from the analysis: the patient as a unique person with resources and abilities, despite limitations, and the carers' awareness of their own professional approach. It seemed as if the supervision and the use of a comprehensive and detailed assessment tool contributed to increased knowledge about the patients and to efforts to see them as real persons behind the dementia surface.

Using standardized assessment instruments may help staff identify needs, problems and resources which could be a basis for nursing care, and facilitate and improve the quality of documentation. The Resident Assessment Instrument/Minimum Data Set (RAI/MDS) especially developed for the care of elderly people, was used as a basis for individualized and documented nursing care. This study was carried out to compare nursing documentation in three nursing home wards in Sweden, before and after a one-year period of supervised intervention. The review of documentation focused on structure and content in both nursing care plans and daily notes. The greatest change seen after intervention was the writing of care plans for the individual patients. Daily notes increased both in total and within parts of the nursing process used, but reflected mostly temporary situations. Even though the documentation of nursing care increased the most, it was the theme medical treatment which was the most extensive overall. A difference was seen between computer-triggered Resident Assessment Protocol (RAP) items, obtained from the RAI/MDS assessments, and items in the nursing care plans; the former could be regarded as a means of quality assurance and of making staff aware of the need for further discussions. The RAI/MDS instrument seems to be a useful tool for the dynamic process in nursing care delivered and as a basis for documentation. The documentation should communicate a patient's situation and progress, and if staff are to be able to use it in their everyday nursing care activity, it must be well-structured and freely available. The importance of continuing education and supervision in nursing documentation for development of a reliable source of information was confirmed by the present study.

Multidimensional functional assessment is the basis of individualized care. It is especially important in the care of elderly, with the complexity of symptomatology and often with cognitive impairment present. An assessment instrument for elderly persons, used in this study, is the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) and its incorporated MDS Cognitive Performance Scale (CPS). The purposes of the study were to demonstrate the cognitive performance in elderly persons in different levels of care by using the CPS and to elicit the views of staff on use of the RAI/MDS. Cognitive impairment was found in 1276 elderly persons in six levels of care studied, an important factor to consider when organizing care of elderly. An intervention study was carried out for 1 year in three nursing home wards, with training and supervision in implementation of the RAI/MDS including individualized and documented care. Part of a questionnaire was used to evaluate staff (n = 50) views on using the instrument. A majority of the staff thought that the RAI/MDS could contribute to the improvement of quality of care, documentation in nursing records, and in co-operation and engagement. Further research is necessary to elicit more knowledge on the usefulness and benefits of the instrument.

1. A phenomenological-hermeneutic approach was used to illuminate carers' video-recorded interactions in connection with supervision for individualized nursing care. 2. In order to disclose any changes in the carers' interactions with patients suffering from severe dementia the video recordings were conducted before, during and after the intervention. 3. The content of the videos was transcribed as a text, mainly verbal communication. Due to the rich data the videos and text were kept together as a whole in every step of the analysis. 4. After an initial naïve understanding, different subthemes emerged in the structural analyses: promoting competence, struggling for co-operation, deep communication for communion, showing respect for the unique person, skills in balancing power, distance in a negative point of view, and fragmentary nursing situations. 5. The overall theme was 'Carers' balancing in their interactions, verbal as well as non-verbal, to promote a sense of mutual togetherness with the patient'. 6. The supervision intervention contributed to an improvement in carers' skills in balancing in their interactions. In the caring process carers' and patients' shared experiences and, due to patients' disabilities, interactions depended mainly on carers' qualities and capabilities for this confirming nursing care.

BACKGROUND: An intervention project was conducted in three nursing home wards in Sweden. Most patients had severe dementia. The intervention consisted of supervision for individualized and documented nursing care, based on multidimensional assessment. AIM: To illuminate changes in carers' approach after the intervention. METHODS: Several data collections were conducted across the intervention and consisted of nursing documentation, patient life stories as told by carers, video recorded interactions, stimulated recall interviews and a questionnaire. Both quantitative and qualitative methods were used in the analyses. FINDINGS: The findings from the different methods mirrored each other and added to the credibility of the intervention. Communicated knowledge about patients improved in nursing documentation and also as told by carers. Carers were differently skilled in managing the complexity of nursing care situations before as well as after the intervention, but the intervention contributed to developing carers in 'confirming nursing care'. They also improved in their ability to verbalize reflections about their everyday life with patients with dementia. CONCLUSION: Supervision made it possible for carers to share their lived experiences about their day-to-day life with patients, which could promote personal and professional development and thus improve care quality. It also appeared that a detailed assessment tool used as part of the nursing process contributed to seeing a patient as a real person behind a dementia surface.

The self is constructed in cooperation with other people and social context influences how people perceive and express it. People with Alzheimer’s disease (AD) often receive insufficient support in constructing their preferred selves, but little is known about how they express themselves together with other people with AD. In accordance with Harré’s social constructionist theory of self, this study aimed to describe how five people with mild and moderate AD express their Self 2 (i.e., their personal attributes and life histories) in a support group with a facilitator experienced in communicating with people with AD. The participants’ expressions of their Self 2 were analyzed with qualitative abductive content analysis and interpreted in terms of agency and communion and a lack of agency and communion. The findings highlight the importance of supporting a sense of agency and communion when assisting people with AD in constructing their self.

The aim of this study was to use Harré’s social constructionist theory of selfhood to describe how people with mild and moderate Alzheimer’s disease (AD) express their sense of self. The findings show that Self 1, the embodied sense of being a person, was expressed fluently by participants through the use of first-person indexicals. Self 2, the experienced personal attributes and life narrative, had undergone changes. Those changes were not entirely for the worse; participants had also developed new skills in managing life with AD. In a lifetime perspective, those changes were minor and participants perceived themselves to be basically the same people that they were before having AD. When constructing Self 3, the social personae, participants usually described being supported by others, but sometimes described being exposed to malignant positioning. They also feared that they might become more exposed to negative attitudes as their AD progressed. However, participants were understanding towards the offensive behaviours of others.

The sense of self is vulnerable in people with Alzheimer's disease (AD), and might be positively and negatively influenced by research participation. The purpose of this study was to describe how people with AD express their experience of being a research participant with respect to their sense of self. Interviews and support group conversations involving 13 people with mild and moderate AD were analyzed using qualitative content analysis. Three themes were constructed: contributing to an important cause, gaining from participating, and experiencing risks and drawbacks. Participants described contributing to research as being in line with their lifelong values and lifestyles. They expressed contentment and pride about being research participants, emphasized their positive relationships with the researchers, and described participation as a meaningful activity. When research procedures threatened their sense of self, they were able to reason about risks and decline participation.

This chapter focuses on the concept of clinical supervision in the context of nursing care, discussing in particular the dementia care of the elderly. The health care system is characterized by many different specialties, each with its specific problems to solve. In the case of nursing, care is a 24-hr ongoing process, with complex caring situations, more or less urgent, which means that it is mostly unpredictable. The chapter provides a detailed synthesis of supervision objectives and considers kinds of resources that are required to provide adequate supervision. It also talks about the influence of clinical supervision on family- and professional caregivers and outlines one of the authors′ studies, which examined organizational factors in relation to supervision. The chapter indicates how efficient interventions can encourage those who care for elderly with cognitive impairment to accept and implement new knowledge about psychosocial methods, improving the quality of care.

AIM: To evaluate a new supervision model for nursing students' placements in primary care in Sweden and to document students' opinions on their learning experiences in this setting. METHOD: Nursing students' (n=238) opinions were collected using a questionnaire administered before and after implementation of a new supervision model for student placements in primary care. RESULTS: Respondents were generally satisfied with their placements and rated factors that supported the new model: distinct structure for following students during the placement period; continuous caring experiences with some patients; having more than one district nurse as a mentor during the period; and seminars in primary care settings. However, just one third of respondents felt that they gained insight into how nursing research could be used in patient care. CONCLUSION: The evaluation of the new supervision model and learning opportunities in primary care were positively rated by respondents. Application of nursing research and planned time for reflection were ranked low, findings that are noteworthy and should be investigated further.

Living with dementia disease (DD) can include difficulties describing experiences of everyday lives, which can lead to withdrawal, social isolation or existential homelessness. Persons with DD living in nursing homes are mainly dependent on the nurses for establishing and maintaining relationships with those around them. It can be challenging for nurses to understand what a person with DD is trying to express and to make themselves understood in turn. The validation method is intended to facilitate communication with persons with DD, but to our knowledge, there have been no qualitative studies of how this influences persons’ communication. This study aimed to illuminate the actions and reactions of persons with DD living in nursing homes in one-to-one conversations with nurses during 1 year of validation method training, as observed in videotapes. Four persons with DD were involved in videotaped conversations with four nurses who were participating in a validation method training programme. Videotapes with at least 5 months between the first and last recording were analysed and compared qualitatively. The findings are presented in four categories that were identified to various degrees in conversations at the beginning and at the end of the programme: being uninterested in or unable to answer questions, talking about more than one topic of conversation at the same time, trying to talk about what is on one’s mind and speaking more freely about what is on one’s mind. In the videotaped conversations at the end of the programme, the persons had the opportunity to use their remaining communication abilities. This may have been related to the development of the nurses’ communication skills during the training programme, and so it is possible that persons with DD could benefit from communicating with nurses trained in the validation method.

Background: Training nursing staff in communication skills can impact on the quality of care for residents with dementia and contributes to nurses' job satisfaction. Changing attitudes and practices takes time and energy and can affect the entire nursing staff, not just the nurses directly involved in a training programme. Therefore, it seems important to study nurses' experiences of a training programme and any influence of the programme on work climate among the entire nursing staff.

Aims and objectives: To explore nurses' experiences of a 1-year validation method training programme conducted in a nursing home for residents with dementia and to describe ratings of work climate before and after the programme.

Design: A mixed-methods approach.

Methods: Twelve nurses participated in the training and were interviewed afterwards. These individual interviews were tape-recorded and transcribed, then analysed using qualitative content analysis. The Creative Climate Questionnaire was administered before (n = 53) and after (n = 56) the programme to the entire nursing staff in the participating nursing home wards and analysed with descriptive statistics.

Results: Analysis of the interviews resulted in four categories: being under extra strain, sharing experiences, improving confidence in care situations and feeling uncertain about continuing the validation method. The results of the questionnaire on work climate showed higher mean values in the assessment after the programme had ended.

Conclusion: The training strengthened the participating nurses in caring for residents with dementia, but posed an extra strain on them. These nurses also described an extra strain on the entire nursing staff that was not reflected in the results from the questionnaire. The work climate at the nursing home wards might have made it easier to conduct this extensive training programme.

Implications for practice: Training in the validation method could develop nurses' communication skills and improve their handling of complex care situations.

Nursing homes are a setting in which death and dying is common. How death and dying is articulated and the actions that take place in a nursing home constitute adiscourse that guides the staff in their work. The aim of this studywas to explore thediscourse of death and dying in nursing homes from the perspective and understandingof the staff. The study draws on Foucault’s discourse analysis. Data arefrom fivefocus-group discussions held with 28 staff of four different nursing homes in Sweden. The findings show that the discourse had three characteristics :(a) dying was silent and silenced, (b) emotions were pushed into the background,and (c) attentiveness to death arose after the moment of the elderly person’s death. The structure of the discourse was characterised by a movement between twopositions, avoiding and confronting death, themain focus being on avoidance. Thearticulation and practices of silence highlight a need to regard dying as a processthat requires attention. One way to ensure appropriate attention could be to instil the philosophy of palliative care in nursing homes, including training and supportfor the staff in their work. The study demonstrates that nursing-home staff needmore knowledge and support to enable them to feel that they do a good job.

Seven care managers employed by a large municipality in Sweden were interviewed concerning their reasoning regarding end-of-life care for older people. Data were analyzed using a hermeneutic approach. The results showed that end-of-life care was considered to constitute a small part of the care managers' work and was something they did not focus on in general when assessing care needs. Two different pathways to death--the natural and the medical--were identified. In the natural pathway, death was invisible and the care was more routine-oriented. In the medical pathway, death was visualised and the care more individualised. Neither of the pathways paid attention to communication or existential needs. Thus, there is a need for a palliative pathway to death based on the philosophy of palliative care, which could provide guidance for care managers and promote opportunities for older people to achieve a dignified dying and death.

In Sweden, increased care in ordinary housing has contributed to a reduction of rooms in sheltered accommodation. The allocation of rooms has become stricter. Only those whose care needs cannot be met in any other ways are allocated such accommodation. The aim was to explore the waiting time between the transfer decision and the accomplishment of the move from the initial form of care to sheltered accommodation as well as whether there were differences in waiting time in relation to certain demographic data. METHOD: 445 decision documents were analysed. Mean and 95% confidence intervals (CI) for waiting time and date of the move to sheltered accommodation were calculated. Differences between mean age and waiting time were analysed using Student's T-test. Effects of age, gender and cohabitation on waiting time were estimated by means of multifactor linear regression. RESULTS: The main finding was that the difference in mean waiting time was shortest when moving from hospital, irrespective of destination. There were no significant differences in waiting time in relation to gender, age or cohabitation. CONCLUSION: The reason for a move was often described by means of abstract standard formulations. There is a need for standardised models and assessment instruments in order to ensure older people's safety and to compare different forms of accommodation.

Aim: The aim of the study was to deepen the understanding of how older persons living in a nursing home experience life close to death.

Background: A move to and a life in a nursing home while being close to death is a reality for many older people in Sweden. Being able to express thoughts and feelings about death has been described as both crucial for sustaining personhood as well as for establishing a meaningful existence at the end of life. Important are the experiences of older people living in nursing homes who are approaching death.

Method: Six older people were interviewed on one to four occasions. A total of 16 interviews were conducted with the participants. An interpretative approach was chosen.

Findings: The main interpretation, Feeling lonely in an unfamiliar place, is based on three themes (i) Waiting for death, with the subthemes death as a release and thinking of oneself as dead; (ii) Subordinate oneself to values and norms of the staff, with the subthemes feeling offended and feeling trapped; and (iii) Keep the courage up. The older people's lives were characterised by feelings of aloneness in an unfamiliar place which contributed to a sense of existential loneliness. They experienced few opportunities to discuss their thoughts of life and death, including preparations for passing away.

Conclusion and implication for practice: It is of importance for professionals to be able to meet older people as they are and respect them as human beings in their transitions, before, during and after the move to a nursing home. It is important to find ways to support older people's wellbeing and identity near death.