| 1. |
- Backman, Annica, 1972-
(author)
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Leadership : person-centred care and the work situation of staff in Swedish nursing homes
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Background: Swedish nursing home managers, who constitute the empirical focus of this thesis, hold overall operational responsibility for the nursing homes, which includes the care of residents, direct care staff and work environment. Aged care organisations are also expected to provide person-centred care. Working towards a person-centred approach poses new demands and leads to challenges for leaders, and there is currently limited knowledge of what characterises leadership that promotes a person-centred approach. In addition, an ongoing demographic shift in the aged care workforce entails further challenges, as the proportion of professional workers is decreasing. Leading a healthy work environment is therefore important for ensuring and protecting staff health. Based on this, it is important to explore nursing home managers’ leadership in relation to person-centred care and the work situation of staff.Aim: The overall aim was to explore leadership in relation to person-centred care and the work situation of staff in Swedish nursing homes.Methods: This thesis is based on data from two data collections. First, it includes cross-sectional baseline data from a national inventory of health and care in Swedish nursing homes (SWENIS) collected in 2013-2014. The SWENIS dataset consists of a sample of staff n=3605 from 169 nursing homes in 35 municipalities, and nursing home managers n=191. The second data collection consists of 11 semi-structured interviews with 12 nursing home managers in highly person-centred nursing homes that already participated in SWENIS. Data were explored via descriptive statistics, simple and multiple regression analyses, and qualitative content analysis.Results: Leadership was positively associated with person-centred care and psychosocial climate. Highly rated leadership behaviors’ among nursing homes managers was characterized by experimenting with new ideas, controlling work closely, relying on his/her subordinates, coaching and giving direct feedback, and handling conflicts constructively. Leading person-centred care can be outlined by four leadership processes: embodying person-centred being and doing; promoting a person-centred atmosphere; maximizing person-centred team potential and optimising person-centred support structures. Leadership was also positively associated with social support and negatively associated with job strain. Further, the variation in leadership was to a very small extent explained by the nursing home managers’ educational qualification, operational form of the nursing home and the number of employees in a unit.Conclusions: All findings point in the same direction: that leadership, as it is characterized and measured in this thesis, is significantly associated with person-centred care provision as well as with the work situation of staff. This suggests that nursing managers have a central leadership role in developing and supporting person-centred care practices, and also in creating a healthy work environment. The results also highlight five specific leadership behaviours that are most characteristic of highly rated leadership, thereby adding concrete descriptions of behaviours to the literature on existing leadership theories. The findings also include four central processes for leading towards person-centred care in nursing homes. Taken together, it seems important for managers to translate the person-centred philosophy into actions and to promote an atmosphere pervaded by innovation and trust, in which cultural change is enhanced by positive cultural bearers. Utilizing the overall knowledge and competencies among staff and potentiating care teams was also considered important for leading person-centred care, along with optimising supportive structures for supporting and maintaining person-centred care. If aged care organisations are to be committed to person-centred care, an important implication seems to be to organise nursing homes in a way that allows nursing home managers to be close and present in clinical practice and actively lead towards person-centred care. The findings of this thesis contribute to our understanding of leadership in relation to person-centre care and the work situation of staff. These findings can be used in leadership educations and nursing curriculum. Longitudinal studies would be valuable for following leadership, person-centred care and the work situation of staff over time.
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| 2. |
- Andersson, Sofia, 1972-
(author)
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Vård i livets slutskede på särskilt boende för äldre personer : närstående och vårdpersonals skattade och berättade erfarenheter
- 2017
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Doctoral thesis (other academic/artistic)abstract
- Bakgrund I Europa, blir det allt vanligare att äldre personer dör på särskilt boende i stället för på sjukhus. Särskilda boenden spelar därför en viktig roll när det gäller vård i livets slutskede. Målet med palliativ vård för personer med livshotande sjukdom och deras närstående är att öka livskvaliteten och lindra lidande. Strukturerade vårdplaner såsom Liverpool Care Pathway for care of the dying (LCP) kan vara ett sätt att öka vårdkvaliteten. Det saknas dock forskning om vård i livets slutskede på särskilda boenden när en strukturerad vårdplan har använts.Syfte Det övergripande syftet med avhandlingen var att beskriva vård i livets slutskede på särskilt boende för äldre personer utifrån närstående och vårdpersonals skattade och berättade erfarenheter.Metod Avhandlingen baseras på två kvantitativa (I, II) och två kvalitativa (III, IV) studier. Studie I baseras på frågeformuläret Views of Informal Carers – Evaluation of Services (VOICES) som har besvarats av närstående (n = 189) efter att en anhörig har dött. Data har därefter analyserats med beskrivande och jämförande statistik. Studie II baseras på data om alla förväntade dödsfall (n = 22 855) som registrerats i Svenska palliativregistret (SPR). Dödsfallsenkäten har besvarats av vårdpersonal och svaren har sedan analyserats med beskrivande statistik och univariat och multipel logistisk regressionsanalys. Studie III baseras på fokusgruppsintervjuer och enskilda intervjuer med vårdpersonal. Studie IV baseras på enskilda intervjuer med närstående. Data från studie III och IV har analyserats med hjälp av kvalitativ innehållsanalys.Resultat Resultatet i studie I visar att majoriteten av de närstående skattade att den äldre personen fick tillräcklig hjälp såväl med personlig vård (78,5 %) som med sjukvård (93,0 %) de sista tre dagarna i livet. De närstående (86,2 %) rapporterade att de var informerade om att det var sannolikt att den äldre personen skulle avlida och majoriteten (94,1 %) av de äldre hade avlidit på önskad plats. Resultatet visade dock på hög förekomst av smärta (46,5 %) och andnöd (55,9 %). Det var ingen skillnad mellan åldersgrupperna när det gällde smärta men de äldre < 85 år hade signifikant högre förekomst av andnöd (70,6 %) jämfört med de äldre äldre, ≥ 85 år, (47,5 %). De äldre, < 85 år, hade signifikant oftare symtomlindring för andnöd (53,1 %) jämfört med äldre äldre, ≥ 85 år, (31,8 %).Resultatet i studie II visar hög förekomst av smärta (68,8 %) och ångest (44,0 %). Faktorer associerade med symtomlindring av smärta, illamående, ångest och andnöd var dels att validerat smärtskattningsinstrument hade använts, dels att munhälsan var bedömd. Starkast samband var det mellan symtomlindring av tre symtom (smärta, andnöd och ångest) och att injektioner var förskrivna vid behov.Resultatet i studie III visar att vårdpersonalen upplevde sig tryggare efter implementeringen av LCP genom att de hade fått ett gemensamt förhållningssätt, kände stöd att skräddarsy vården utifrån den döende personens individuella behov, kände stöd att involvera närstående i beslut och i vården samt hade blivit mer medvetna om vårdmiljön.Resultatet i studie IV visar att närstående upplevde sig tryggare i en välbekant och varm atmosfär, att vara kontra inte vara involverad i vård i livets slutskede och att bli tröstade genom att bevittna vårdpersonalens strävan att lindra lidande.Konklusion Resultatet från studierna i den här avhandlingen pekar på hög vårdkvalitet i livets slutskede på särskilt boende genom god omvårdnad, men resultatet pekar också mot förekomst av inadekvat symtomlindring och hög förekomst av smärta, andnöd och ångest de sista dagarna i livet. Det framkom ett tydligt samband mellan ordinerade injektioner vid behov och symtomlindring av smärta, illamående och ångest. Resultatet indikerar även vikten av att använda smärtskattningsinstrument och göra munhälsobedömningar för symtomlindring vid vård i livets slutskede. Således kan ett sätt att öka vårdkvaliteten för döende personer vara att det finns ordinerade injektionsläkemedel vid behov mot vanliga symtom, att använda validerade smärtskattningsinstrument och att göra munhälsobedömningar. Det framkom också att användandet av en standardiserad vårdplan såsom LCP kan vara ett sätt att förbättra vården för de äldre personerna i livets slutskede. Såväl vårdpersonalen som de närstående upplevde stöd av den struktur för bedömningar och vårdaktiviteter som LCP ger. Vårdpersonalen upplevde också stöd i att involvera närstående i vården och i vårdrelaterade beslut.
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| 3. |
- Boman, Erika, 1975-
(author)
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Inner strength as a health resource among older women
- 2016
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Doctoral thesis (other academic/artistic)abstract
- Background Long life does not inevitably mean more healthy years; older women have an increased risk of disabilities, diseases and adverse life events. Nevertheless, many older women experience health. This may be explained by possessing resources that promote health, despite adversities. Inner strength is seen as a resource as such. In this thesis inner strength is interpreted according to a theoretical model where inner strength comprises four interrelated and interacting dimensions: connectedness, creativity, flexibility and firmness, and being rated by the Inner Strength Scale (ISS).Aim and methods The overall purpose of this thesis was to explore inner strength as a health resource among older women. In study I six focus group interviews were performed with older women (66-84 years; n = 29) and the interviews were analysed by a concept driven approach and by means of qualitative content analysis. Studies II–IV had a quantitative, cross-sectional design. A questionnaire was sent to all older women (65 years and older) living in Åland, an autonomous island community in the Baltic Sea, and 1555 (57%) women responded. The data was analysed using descriptive and inferential statistics.Results In study I, exploring how inner strength and its dimensions can be identified in narratives of older women, connectedness was interpreted as a striving to be in communion, creativity as the ability to make the best of the situation, firmness as having a spirit of determination – “it is all up to you”, and flexibility as a balancing act. The results of study II showed that strong inner strength was associated with better mental health, but not physical health. In exploring factors associated with health-related quality of life, fewer symptoms of depressive disorders was the strongest explanatory variable, and together with not feeling lonely associated with better both physical health and mental health. Better physical health was also explained by not having a diagnosed disease, being of lower age and the opportunity to engage in meaningful leisure activities. Better mental health was additionally explained by having enough money for personal needs. In study III the result showed that non-depressed women were likely to have a strong inner strength, as well as never or seldom feeling lonely, taking fewer prescribed drugs, feeling needed and having the opportunity to engage in meaningful leisure activities. In study IV poorer mental health was associated with weaker inner strength in total, and in all four dimensions of inner strength. Symptoms of depressive disorders and feeling lonely were related to lower scores in three of the dimensions (except firmness and creativity, respectively) and poorer physical health was associated with lower scores in two of the dimensions (firmness and flexibility). Some other health threats were significantly associated with only one of the dimensions (connectedness or creativity), and others were not significantly associated at all.Conclusion The results add nuance to the notion of inner strength and deepen empirical knowledge about the phenomenon. It is elucidated that the ISS can be used not only to rate inner strength but also to offer guidance as to the areas (i.e. dimensions) in which interventions may be profitable. It is further shown that inner strengths can be identified in narratives of older women. Mental ill health has shown to have overall the strongest association with weakened inner strength among community-dwelling older women. The causality can, though, not be studied due to the cross-sectional design; therefore, longitudinal studies are recommended. Notwithstanding that limitation, the findings can be used as a knowledge base in further research within this field.
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| 4. |
- Claesson Lingehall, Helena, 1965-
(author)
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Delirium in older people after cardiac surgery : risk factors, dementia, patients’ experiences and assessments
- 2016
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Doctoral thesis (other academic/artistic)abstract
- Background:Delirium is common in older people undergoing cardiac surgery. Delirium is an acute or subacute neuro-psychiatric syndrome, characterized by a change in cognition, disturbances in consciousness; it fluctuates, develops over a short period of time and always has an underlying cause. It is associated with a disturbance in psychomotor activity, and is classified according to different clinical profiles such as hypoactive, hyperactive and mixed delirium. Delirium after cardiac surgery is not harmless, it increases the risk of complications such as prolonged stay in hospital, falls, reduced quality of life, reduced cognitive function and increased mortality.Aim:The overall aim of this thesis was to investigate postoperative delirium in older people undergoing cardiac surgery with Cardiopulmonary Bypass (CPB), focusing on risk factors, dementia and patients’ experiences; and to evaluate an assessment for screening delirium.Methods:This thesis compromises four studies. All participants (n=142) were scheduled for cardiac surgery with use of CPB at the Cardiothoracic Surgery Department, Heart Centre, Umeå University Hospital, Sweden, between February and October 2009. Six structured interviews were conducted preoperatively, day one and day four postoperatively, and in home visits, one, three and five years after surgery (2010, 2012 and 2014). The assessment scales used in Studies I, II and IV were: the Mini-Mental State Examination (MMSE) for cognition, the Organic Brain Syndrome Scale (OBS) for delirium, Geriatric Depression Scale 15 (GDS-15) for depression, Katz staircase with Activities of Daily Living (ADL) for participants’ functional status and the Numerical Rating Scale (NRS) for pain. During the hospital stay, nursing staff used the Swedish version of the Nursing Delirium Screening Scale (Nu-DESC) to assess delirium. Semi-structured interviews were also carried out (III) in the one-year follow up. Delirium, dementia and depression were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR).Results: Out of 142 participants 54.9% (78/142) developed delirium after cardiac surgery (I). Independent risk factors, predisposing and precipitating, associated with delirium were: age, diabetes, gastritis/peptic ulcer, volume load during operation, longer time on ventilator in intensive care, increased temperature and plasma sodium concentration in the intensive care unit. Out of 114 participants thirty (26.3%) developed dementia within the five years of follow-up. It was shown that a lower preoperative MMSE score and postoperative delirium were factors independently associated with development of dementia (II). One year after cardiac surgery, participants diagnosed with postoperative delirium described in detail feelings of extreme vulnerability and frailty. Despite this, the participants were grateful for the care they had received (III). Hypoactive was the most common symptom profile for delirium. The Swedish version of Nu-DESC showed high sensitivity in detecting hyperactive delirium, but low sensitivity in detecting hypoactive delirium (IV).Conclusion:Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to postoperative delirium. Preventive strategies should be considered in future randomized studies. It might also be suggested that cognitive function should be screened for preoperatively and patients who develop delirium should be followed up to enable early detection of symptoms of dementia. Whether prevention of postoperative delirium can reduce the risk of future dementia remains to be studied. To minimise unnecessary suffering, patients and next of kin should be informed about and prepared for the risk of delirium developing during hospitalization. The Swedish version of Nu-DESC should be combined with cognitive testing to improve detection of hypoactive delirium, but further research is needed. Healthcare professionals need knowledge concerning postoperative delirium in order to prevent, detect and treat delirium so as to avoid and relieve the suffering it might cause.
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| 5. |
- Hedberg, Pia, 1972-
(author)
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Purpose in life among very old people
- 2010
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Doctoral thesis (other academic/artistic)abstract
- The aim of this thesis is to explore purpose in life among very old people. The proportion of elderly is increasing in Sweden, especially among the group of very old aged over 85 years. Ageing has been associated from some perspectives with health, wisdom, maturity, and inner strength. Ageing can also, however, lead to reduced physical function, cognitive impairments, and loss of purpose in life. A loss of purpose in life can lead to mental health problems such as depression. This thesis is part of the Umeå 85 + study/GERDA begun in 2000. Half of all 85-year-olds, all 90-year-olds, and all those 95 years of age or older living in the municipality of Umeå were invited to the larger study, which was expanded in 2002 to include five rural municipalities in Västerbotten County with the same inclusion criteria. The Umeå 85 + study/GERDA is a collaborative project between several departments at Umeå University.Selection criteria for participants in the thesis were the ability to answer Likert-type questionnaires and the ability to participate in interviews. A follow-up study was conducted in Umeå in 2005 and in Västerbotten County in 2007. Paper I is a cross-sectional study with 189 participants (120 women and 69 men) who had responded to several questionnaires including the Purpose in Life test (PIL). In the results women scored significantly lower on the PIL test than men; attitudes towards one’s own aging were associated with purpose in life for both men and women; and musculoskeletal disorders were associated with lower purpose in life in women. Paper II includes the 189 participants from study I. In results at baseline the 40 who were diagnosed with depression had significantly lower purpose in life, and women were diagnosed with depression more often than men (32/120 women and 8/69 men). The 40 participants with a diagnosis of depression were excluded five years later, when 78 of 149 participants were available for the follow-up, 21 of whom (26.9%) had developed depression. There was no difference in the mean scores on the PIL test between those who had developed depression and those who had not. Purpose in life does not seem to protect very old people from developing depression.Paper III includes 51 people who responded to the PIL test on two occasions five years apart, and its results show that purpose in life decreased after five years. There was no difference in mean PIL scores at baseline between those with a diagnosis of depression and those without depression, but purpose in life declined significantly over the five years in those with diagnosed depression. In study IV, to gain a deeper understanding of purpose in life, content analysis was conducted on interviews from 30 women. To obtain 5 variety and breadth in the stories we selected 10 women with low estimated purpose in life, 10 women with undecided estimated purpose, and 10 women with high estimated purpose in life. The results show that despite the fact that women estimated their purpose in life lower than men, their stories were positive. The women experienced purpose in their daily life where social relations was important and on a spiritual level. However, there were also expressions of experiencing life as simply existing. In Study V we included 23 men who had responded to a question about purpose in life. Their answers were subjected to content analysis and the results show that for men work is an important part of purpose in life. All men except one had a positive outlook on life, and the men found purpose in life most strongly in memories of when they were younger.Lack of purpose in life can result in mental disorders like depression. Stereotypes of older people can affect their views of their own ageing, which in turn can weaken their purpose in life. To prevent mental illness it is important to experience purpose in life throughout life. Society at large and the health care system must consider purpose in life integral to mental health and work to combat ageist stereotypes to support purpose in life through the entire lifespan.
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| 6. |
- Nilsson, Anita, 1960-
(author)
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Att vårda äldre personer med kognitiv svikt i sjukhusmiljöer : attityder, processer, innebörder
- 2013
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Doctoral thesis (other academic/artistic)abstract
- Inledning: Äldre personer med kognitiv svikt, exempelvis i form av demenssjukdom, delirium eller depression, är en vanligt förekommande population inom svensk sjukhusvård. Dessa äldre kan ha särskilda behov till följd av en försämrad kognition, men litteraturen tyder på att akutsjukhusens miljö, organisation och vårdprocesser inte alltid stödjer tillgodoseendet av dessa behov.Syfte: Det övergripande syftet med avhandlingen var att belysa vården av äldre personer med kognitiv svikt i sjukhusmiljöer.Metoder: Avhandlingen består av fyra delstudie. I studie I tillämpades en tvärsnittsdesign för att utforska personalens attityder till äldre patienter med kognitiv svikt, personalens tillfredsställelse med vården och arbetet samt upplevelsen av personcentrerat vårdklimat (n=391). I studie II användes en Grounded theory design för att undersöka hinder för personcentrerad vård för äldre personer med kognitiv svikt på en akutmedicinsk vårdavdelning. I studie III tillämpades en tvärsnittsdesign för att utforska de psykometriska egenskaperna i den svenska versionen av ”The Person-centred care of Older People with cognitive impairment in Acute Care scale” (POPAC) i ett urval av sjukhuspersonal (n=293). I studie IV användes en fenomenologisk hermeneutisk design för att belysa innebörder av att vårda äldre patienter med kognitiv svikt på akuta sjukvårdavdelningar utifrån vårdpersonals (n=13) berättelser.Resultat: Studie I visade att deltagande personal skattade en neutral attityd till äldre patienter med kognitiv svikt i spektret mellan negativa och positiva attityder, samt att faktorer som att vara yngre, undersköterska och att uppleva vården av de äldre som betungande, hade samband med mer negativa attityder. Resultaten visade också att vårdpersonal upplevde att äldre patienters kognition sällan utvärderades under vårdtiden, samt att man sällan baserade vården på evidensbaserade riktlinjer för vård av äldre med kognitiv svikt. Studie II belyste att ett organisatoriskt fokus på medicinska behov, åtgärder och rutiner bidrog till att personal hamnade steget efter i relation till att synliggöra och möta dessa äldre personers multidimensionella behov, och att detta kunde medföra tecken på vårdlidande för de äldre, utanförskap för närstående och frustration för personal. Studie III stödde en fortsatt användning av POPAC-skalan för skattningar av upplevd förekomst av personcentrerade vårdprocesser för äldre patienter med kognitiv svikt, men att ytterligare studier rekommenderades framförallt av skalans olika dimensioner. Studie IV belyste att ju större avstånd som upplevs mellan vad vårdpersonalen kan göra (verklig vård) och vad de vill göra (ideal vård) för äldre patienter med kognitiv svikt i akuta vårdmiljöer, desto meningslösare upplevs vården, och desto större blir hotet mot personalens personlig-professionella integritet. Den tolkade helheten visar på att vårda äldre patienter med kognitiv svikt inom akutsjukvård betyder att försöka ge omvårdnad i miljöer som inte stödjer vårdpersonalens personlig-professionella integritetSlutsatser: En rimlig konklusion av dessa resultat är att det i sjukhusmiljöer där äldre patienter ofta vårdas kan finnas anledning att diskutera och ytterligare studera hur attityder, synsätt på och målsättningar för vården och dess innehåll, åtgärder och interventioner kan främja eller motverka en god omvårdnad för de äldre med kognitiv svikt. Det kan också finnas anledning att se över hur personalen kan stödjas i att ge person-centrerad vård till de äldre, exempelvis genom riktlinjer för vård av äldre personer med kognitiv svikt, standardiserade skattningar av kognition, samt implementering av vårdprocesser som stödjer en personcentrerad vård för dessa patienter. Det kan också finnas behov av att ytterligare kritiskt granska hur organisatoriska och miljömässiga faktorer på avdelningar stödjer eller motverkar en personcentrerad vård för äldre patienter med kognitiv svikt. Därtill kan det finnas behov av att skapa ytterligare förutsättningar för vårdpersonalen att bevara och utveckla sin personlig-professionella integritet genom att utveckla miljöer som ger möjligheter för dem att ge en god omvårdnad till dessa äldre.
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| 7. |
- Olofsson, Birgitta, 1963-
(author)
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Old people with femoral neck fracture : delirium, malnutrition and surgical methods - an intervention program
- 2007
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Doctoral thesis (other academic/artistic)abstract
- Hip fracture is a global and a growing public health problem. More women than men sustain hip fractures, the incidence increases exponentially with age and mean age is above 80. About one third of hip-fracture patients suffer from dementia and are prone to develop acute confusional state (delirium). Delirium is one of the most common complications after hip-fracture surgery, and seriously impacts on morbidity and mortality. Malnutrition is also common in hip-fracture patients and is associated with postoperative complications, such as delayed healing of the wound, infections and decubitus ulcers. Arthroplasty is usually preferred procedure in displaced femoral neck fractures but is, however, controversial in patients with dementia due to the fear of dislocation of the prosthesis. The aims of this thesis are to identify risk factors for delirium and the impact of delirium on rehabilitation outcome, to evaluate whether a postoperative multi-factorial intervention program could reduce delirium, to investigate the effect of a nutritional intervention and to evaluate complications, functional outcome and mortality regarding two surgical methods, hemiarthroplasty (HAP) and internal fixation (IF), in old patients with femoral neck fracture. Thirty-eight out of 61 consecutive patients (62%) were delirious on admission to hospital or developed postoperative delirium. An increased risk of postoperative delirium was found among hip-fracture patients with dementia and/or depression. Delirious patients were hospitalized longer, were more dependent in their activities of daily living, had poorer psychological well-being and suffered more complications than non-delirious patients. A postoperative multi-factorial and multidisciplinary intervention program reduced the incidence, at 55% vs 75% (p=0.003), and number of days with delirium, 5 vs 10 days (p=0.009). Postoperative complications were also reduced; decubitus ulcers 9% vs 22% (p= 0.010), urinary tract infections 31% vs 51% (p=0.005), falls 12% vs 27% (p=0.007), and the mean hospitalization period was 10 days shorter in the intervention group (p=0.030). Malnutrition was common among all these patients (53 %) and associated with postoperative complications such as decubitus ulcers and delirium. However, the nutritional intervention had no effect on nutritional parameters at four months, nevertheless men had better nutritional outcomes than women. A higher proportion of patients with dementia operated on using HAP had regained their pre-fracture ability to walk independently at the one-year follow up compared with those operated on using IF. Six of 83 patients dislocated their HAP during hospitalization and during an episode of delirium, none had dementia. No difference in mortality between the surgical methods was seen. Dementia per se should not be a reason to disqualify patients from being treated with the most appropriate surgical method. It is clinically important to discriminate between dementia and delirium, since delirium can be prevented and treated even in patients with dementia. Old patients undergoing surgery have special needs that are not always catered for in ordinary orthopaedic or surgical wards. The special care for these patients should include: a combined nursing and medical care based on comprehensive geriatric assessments, systematic prevention, detection and treatment of postoperative complications such as delirium, hypoxemia, urinary tract infections, pain, malnutrition and an active rehabilitation. It is obvious that improved quality of care reduces patient suffering and seemingly the costs for society.
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| 8. |
- Åhlin, Johan, 1975-
(author)
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Stress of conscience and burnout among healthcare personnel working in residential care of older people
- 2015
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Doctoral thesis (other academic/artistic)abstract
- Background This thesis was part of the research programme ‘Stress of Conscience and Burnout among Healthcare Personnel in Elderly Care’ at Umeå University. Relationships have been found between stress of conscience, perception of conscience, burnout, and social support. No longitudinal studies investigating these relationships have been performed previously, thus it was not known how these relationships develop over time. Neither was it known how stress of conscience and other phenomena of importance might vary between organisations because no comparative studies have been performed. It seems important to organize the care of older people in such a way that healthcare personnel can stay healthy at their workplace, especially because the aging population is expected to grow. Studies have shown that stress of conscience is associated with the well being of healthcare personnel and the quality of care they provide. In order to develop measures against stress of conscience, it seems important to gain a deeper understanding of the aspects in daily work that can generate troubled conscience among healthcare personnel. Aim The overall aim of this thesis was to describe, compare, and investigate longitudinal relationships between stress of conscience, perceptions of conscience, burnout, social support and person-centred care among healthcare personnel working in two different organisations for residential care of older people. Furthermore, the aim was to deepen the understanding of some aspects of importance that generate troubled conscience at each of the two organisations. Based on the emerging knowledge from the research programme and the results from studies І and ІІ, important aspects that can generate troubled conscience among healthcare personnel were shown to be working with guidelines and working during times of downsizing and reorganisation.Methods Studies Ι and ΙΙ took quantitative approaches with a longitudinal design (Ι) and a cross-sectional design (ΙΙ), while studies ΙΙΙ and IV were based on a qualitative approach. In study Ι, the participants were healthcare personnel working in an organisation for residential care of older people with a public mode of operation located in a small town in northern Sweden (baseline n = 488, follow-up n = 277). In study ΙΙ, the participants were healthcare personnel working in two different organisations chosen to be as different from each other as possible regarding their characteristics. In this study, an organisation with a private mode of operation and located in a large city in the south of Sweden (n = 98) was compared to the baseline data from the publically run organisation from the small town in study Ι (n = 488). In studies ΙΙΙ (n = 8) and IV (n = 7), the participants were care providers working at the same public organisation (ΙΙΙ) and private organisation (IV) as in studies Ι and ΙΙ. Quantitative data were analysed using partial least square regression with jack-knife approximate t-tests, hierarchical cluster analysis with multiscale bootstrap resampling, descriptive statistics, hypotheses tests, effect size measures, and confidence intervals. Qualitative data were analysed using qualitative content analysis.Results The main results showed that the healthcare personnel reported higher levels of stress of conscience than have been reported in other studies. Perceiving one’s conscience as a burden, having high levels of emotional exhaustion and depersonalisation, and noticing disturbing conflicts between co-workers were positively associated with stress of conscience. Associations between stress of conscience and perceiving one’s conscience as a burden and burnout were similar among healthcare personnel despite the differences in the characteristics of the organisations they worked in. Women reported higher levels of stress of conscience and less social support from their co-workers compared to men. This thesis also provides new insights about how working according to guidelines and during times of downsizing and reorganisation can be burdensome issues for care providers and can generate troubled conscience. An overall understanding of care providers experiences of guidelines in daily work was revealed as struggling to do their best; prioritising between arcane guidelines while keeping the residents’ needs in the foreground. They described experiences that guidelines were coming from above, were controlling and not sufficiently anchored at their workplace. They also described guidelines as stealing time from residents, colliding with each other, lacking practical use and complicating care, and challenging their judgment. An overall understanding of care providers’ experiences of working during times of downsizing and reorganisation was revealed as perceiving oneself as pinioned in between current circumstances to provide care and what one’s conscience conveyed. They perceived loss of good management, changed working conditions as exhausting and activating their conscience. They also expressed how they perceived troubled conscience when working conditions decreased the quality of care.Conclusion The results is reflected on in relation to a nursing care model as it seems important to understand the results from a society- and organizational perspective as well as from an individual perspective. The results of the thesis show that it is important to provide healthcare personnel with opportunities to follow and express what their conscience tells them at their workplace in order to buffer the effects of stress of conscience. Support, knowledge, involvement, time, and additional resources are key issues that can help care providers to work more constructively with guidelines in their daily practice. The results show that in times of downsizing and reorganisation it is important to exercise leadership that promotes care providers’ feelings of involvement, security, and togetherness in order to relieve some of the healthcare personnel’s burdensome experiences. An overall understanding of the results is that it seems important to organize the residential care of older people in such a way that registered nurses and leaders are able to be present in healthcare personnel’s daily practice. Healthcare personnel need attendant and supportive leaders who can help them to solve various forms of work-related problems and to help them make priorities in the daily care of residents. This seems important regardless of whether the priorities are between guidelines and residents’ needs or a consequence of an increasingly stressful work environment during times of downsizing and reorganisation. Further studies are needed in order to investigate the importance of gender in relation to stress of conscience and if different kinds of support are needed for women than for men in order to buffer the effects of stress of conscience. Finally, more longitudinal multilevel studies are needed in order to investigate how organisations’ characteristics and organisational changes affect healthcare personnel’s levels of stress of conscience.
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