| 1. |
- Snögren, Maria
(författare)
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Munhälsa – Äldre personers upplevelser och vårdpersonals attityder och kunskaper
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bakgrund: Det är känt att äldre personer har bättre munhälsa i dag och fler kvarvarande tänder än tidigare generationer. Det är en komplex uppgift att utföra munvård för att förebygga nedsatt munhälsa på någon annan. Nedsatt munhälsa kan påverka allmänhälsan på olika sätt, till exempel genom smärta och nedsatt aptit. Nedsatt munhälsa kan också vara en bidragande orsak till infektioner lokalt i munnen, men även i andra delar av kroppen. Det har dock visat sig att vårdpersonal (sjuksköterskor, undersköterskor och vårdbiträden) inom kommunal äldreomsorg försummar utförandet av munvård hos äldre personer av olika skäl, däribland tidsbrist, okunskap och bristande rutiner. Vårdpersonal värdesätter kunskap om munhälsa och efterfrågar utbildning om munhälsa och munvård. Kompetensutveckling för vårdpersonal tar tid samtidigt som den digitala utvecklingen och tillgången till digitala tjänster ökar. Digital utbildning kan vara en lösning till att sprida kunskap i en hel arbetsgrupp. Studier har visat på stort värde av möjligheten till interaktivitet, repetition och feedback som tydligt förknippas med ett ökat lärande vid användande av digitala utbildningar. Studier visar även att vårdpersonal som kompetensutvecklas genom utbildning om munhälsa tillhandahåller bättre munvård till äldre personer efter utbildning.Syfte: Det övergripande syftet var att studera äldre personers uppfattning om munhälsa och vårdpersonals attityder till och kunskaper om omvårdnad relaterat till munhälsa. Ytterligare ett syfte var att beskriva vårdpersonals attityder och kunskaper före och efter en digital utbildning i munhälsa och användbarheten av denna.Metod: Avhandlingen inkluderar fyra delstudier varav två har en kvalitativ design, delstudie I och IV, en med kvantitativ design, delstudie II och en med mixad metod, delstudie III. Delstudie I inkluderar äldre personer och delstudie II-IV inkluderar vårdpersonal. Data har samlats in med hjälp av frågeformulär, individuella intervjuer och fokusgruppsintervjuer. Kvalitativ analys genomfördes med hjälp av kvalitativ innehållsanalys i delstudie I och IV. Kvantitativa analyser genomfördes med Psykometrisk utvärdering med klassisk testteori (CTT) kompletterad med Item Response Theory (IRT) i delstudie II och beskrivande statistik och Wilcoxon signed-rank test i delstudie III.Resultat: Resultaten visar att det är komplext att utföra munvård på någon annan och kräver att tid ges till att bygga personkännedom mellan vårdpersonalen och den äldre personen som får hjälp med munvård. Personkännedom beskrivs av vårdpersonal främja och ge trygghet i utförandet av munvård. Äldre personer beskriver att de är experter på sina egna upplevelser av munhälsan och att denna kunskap behöver delas med vårdpersonalen. Personkännedom etableras och uppnås genom att vårdpersonalen skapar förtroende, är närvarande, förutser behov, är pålästa och genom att reflektera över vården. Det är ett förtroende att utföra munvård på någon annan, vilket underlättas av personkännedom. Det ger vårdpersonalen information och bättre förutsättningarna att utföra god munvård och att synliggöra hinder som tids-, personal- och kunskapsbrist. Äldre personer värdesätter en god munhälsa och vårdpersonalen värdesätter kunskap relaterad till munhälsa. Ett sätt att sprida kunskap om munhälsa bland vårdpersonalen är genom digitala utbildningsinterventioner. Kombinationen av teoretisk kunskap med hjälp av digital utbildning och praktiska övningar beskrivs av vårdpersonalen som ett sätt att ge både teoretisk och praktisk kunskap. Att arbeta tillsammans över professionsgränser i omvårdnad kring munvården beskrivs ofta brista inom kommunal äldreomsorg. Arbetet tillsammans upplevs dock fungera bra vid palliativ omvårdnad. Äldre personer beskriver en önskan om hjälp med sin munhälsa när behov uppstår.Slutsatser: Äldre personer värdesätter en god munhälsa och vårdpersonalen värdesätter kunskap relaterad till munhälsa. Munvård är komplex och förutsätter att vårdpersonalen erhåller kunskap, rutiner, tid och samarbetar för att utföra den med god personkännedom om den äldre person. Digital utbildning är ett sätt att öka kunskapen om munhälsa bland vårdpersonalen. En kombination av teori med hjälp av digital utbildning och praktiska övningar bidrar till både teoretisk och praktisk kunskap. Samarbetet kring munvård mellan sjuksköterskor, undersköterskor och vårdbiträden fungerade inte alltid optimalt, däremot fungerade samarbetet bra vid palliativ omvårdnad. Samarbete, tid och kunskap samt reflektion anses vara viktiga faktorer för vårdverksamheter att beakta i framtiden för att god munvård ska kunna utföras inom kommunal äldreomsorg.
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| 2. |
- Nilsson, Maria, 1957-
(författare)
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Promoting health in adolescents : preventing the use of tobacco
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- There is a robust evidence base for the negative health effects from smoking. Smoking is linked to severe morbidity and to mortality, and kills up to half of its regular users. Tobacco use and production also bring other negative consequences such as economic loss for countries, poverty for individuals, child labour, deforestation and other environmental problems in tobacco growing countries. A combination of comprehensive interventions at different levels is needed to curb the tobacco epidemic. Tobacco control strategies at national levels in the western world often include components of information/education, taxation, legislative measures and influencing public opinion. Two approaches have dominated at the meso and micro levels: cessation support for tobacco users and prevention activities to support young people refraining from tobacco use. Smoking uptake is a complex process that includes factors at the societal level as well as social and individual characteristics. At national level, taxation and legislation can contribute to a societal norm opposing tobacco and creating a context for primary prevention aimed at tobacco free youth. There is no magic bullet in primary prevention. At the meso and micro levels, a continued development of knowledge on the underlying mechanisms and primary prevention methods is essential to prevent young people from starting to use tobacco. The overall aim of this thesis was to gain knowledge about factors that influence young people’s use of tobacco and of preventive mechanisms. The specific aims included to study the relation between Tobacco Free Duo, an intervention program targeting youth in Västerbotten County, and tobacco use prevalence. A specific interest was to explore the role adults can play in supporting young people to refrain from tobacco use. The thesis is based on four studies with three separate sets of data, two were quantitative and one was qualitative. The studies were conducted among adolescents (aged 13-15 yr) in Västerbotten County and on national level in Sweden (aged 13, 15 and 17 yr). Tobacco Free Duo is a school-based community intervention that started in 1993. An essential component of the intervention was to involve adults in supporting adolescents to stay tobacco free. Results showed decreased smoking in adolescents among both boys and girls in the intervention area during the study period of seven years. There was no change in a national reference group during the same time period. A bonus effect was a decrease in adult tobacco use in the intervention area. One out of four adults who supported a young person taking part in the intervention stopped using tobacco. In a qualitative assessment of young smokers, starting to smoke was described as a means of gaining control of their feelings and their situation during early adolescence. They expected adults to intervene against their smoking and claimed that close relations with caring adults could be a reason for smoking less or trying to quit smoking. In a quantitative study that used three decades of national data, over time adolescents became more positive toward parental action on children’s smoking. The adolescents strongly supported the idea of parental action, regardless of whether or not they themselves smoked. Adolescents preferred that actions from parents were dissuading their children from smoking, not smoking themselves, and not allowing their children to smoke at home. These results suggest that the Tobacco Free Duo program contributed to a reduction in adolescent smoking among both boys and girls. Using a multi-faceted intervention that includes an adolescent-adult partnership can decrease adolescent smoking uptake. Engaging adults as partners in tobacco prevention interventions that target adolescents has an important tobacco reducing bonus effect in the adults. The intervention has proven sustainable within communities. A growing majority of adolescents support parental interventions to help them refrain from tobacco. The findings dismiss the notion that adolescents ignore or even disdain parental practices concerning tobacco. A common and consequent norm against tobacco from both schools and parents using a supportive attitude can prevent tobacco use in young people.
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| 3. |
- Ahlborg, Mikael, 1985-
(författare)
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Social capital and inequalities in mental health among young adolescents in Sweden
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to explore social capital and inequalities in mental health among young adolescents in Sweden. This is a compilation thesis comprising four studies. Studies I and II are quantitative studies of crosssectional data from the Swedish Health Behaviour in School-aged Children survey. The aim of Study I was to investigate socioeconomic inequalities in health using both a subjective and an objective measure of socioeconomic status among Swedish adolescents. The findings showed that subjective socioeconomic status robustly and independently predicted mental health problems, poor life satisfaction and poor general health perception. The association between objective socioeconomic status and mental health was weakened, and even reversed, when subjective socioeconomic status was accounted for in regression models. A Latent Profile Analysis was applied in Study II with the aim of identifying distinct profiles of family, school and peer social capital in a nationally representative sample of adolescents and to explore health outcomes in those profiles. The findings showed that five distinct profiles best represented the data for 11 and 15-year olds, while a four-profile model was optimal for 13-year olds. Significant inequalities were identified between profiles when these were examined in terms of mental health problems and life satisfaction. The design of Study III was a qualitative semi-structured interview study. The aim was to explore social capital from the perspective of adolescents in relation to mental health. Adolescents spoke of having access to a safe space, feeling connected to others and predictability as important aspects of social relationships and networks in relation to mental health. The aim of Study IV was to identify and evaluate the design and psychometric properties of instruments for assessing social capital specifically developed and validated for self-reporting among adolescents (10-19 years). The design was a systematic review, in which 20 instruments were identified. The results revealed a lack of instruments that covered both the multidimensionality of social capital and contextual relevance in relation to adolescents. The conclusion from this thesis is that social capital may be useful for identifying vulnerable individuals and for differentiating between the natural imbalance of adolescence and what may lead to serious illness. Longitudinal research and refinement of the operationalization of the concept are, however, needed to enhance the understanding of these findings.
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| 4. |
- Hayati, Elli Nur, 1966-
(författare)
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Domestic violence against women in rural Indonesia : searching for multilevel prevention
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Domestic violence has been recognized globally as one of the most important Public Health concerns with severe negative health consequences for the exposed women. Through UN bodies several international milestones have successfully pushed attention towards worldwide improvements in the life situations of women. Since the ratification of the Convention on Elimination of All Forms of Discrimination against Women (CEDAW) in 1984, significant positive changes towards equality between men and women in Indonesia have been initiated, one being the enactment of the Domestic Violence Act in 2004. However, there is still a need to improve the knowledge about what preventive measures that are feasible and work in different settings. This thesis aims to contribute to a better understanding of appropriate prevention strategies against domestic violence in rural Indonesia by exploring: i) risk factors for domestic violence; ii) women’s ways of coping with exposure to violence; iii) men’s views on masculinity and violence within marriage; and iv) challenges faced by local service agency in managing services for women survivors of domestic violence.Methods: Data from a cross sectional population based study was used to analyze risk factors for physical and sexual abuse among a cohort of pregnant women in Purworejo district. Further, a qualitative phenomenological interview study was conducted to reveal the dynamics of coping among women survivors of domestic violence in the same district. A Grounded Theory study based on focus group discussions with men formed the basis for a situational analysis of the linkage between masculinity and the use of violence within marriage. Finally, a qualitative case study was performed to explore the management practices of a local service agency in the district, to understand the challenges faced in their efforts to address domestic violence.Results: Sexual violence was associated with husbands’ demographic characteristics (age and low educated) and women’s economic independence. Exposure to physical violence among women was strongly associated with husbands’ personal characteristics. The attitudes and norms expressed by women confirmed unequal gender relationships. Experiencing violence led women to using an elastic band coping strategy, moving between actively opposing the violence and surrendering or tolerating the situation. The national gender equality policies were shown to have played a crucial role in transforming gender power relations among men and women (the gender order) in the Indonesian society. Three different positions of masculinity were identified, the traditionalist, the egalitarian, and the progressive, with different beliefs about men’s role within marriage and with various levels of accepting the use of violence. Long term structural preventive efforts and individual interventions targeted to the conflicting couples were preferred over reporting the abuser to the authorities. The major challenges faced by the local service agency were the low priority given by the authorities, mirrored also in low involvement in the daily service by the assigned volunteers. The local agency also stammered in translating the current law and policies into a society that held on to traditional and religious norms regulating the relationships between men and women.Conclusion: Overall, this thesis illustrates that sociocultural traditions and religious teaching still viscously influence people’s attitudes and beliefs about the use of violence within relationships. Domestic violence has not been accepted as a criminal act but is still to a large extent seen as a private family affair. Culturally sensitive programs aimed to bridging the gap between the current laws and policies and the socio-cultural traditions need to be further developed to protect women from domestic violence and increase gender equity in the Indonesian setting.
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| 5. |
- Wastesson, Karin, 1986-
(författare)
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Learning Managerial Work : First-line Managers’ Learning in Everyday Work within Swedish Elderly Care
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This study’s overall aim is to contribute knowledge about first-line managers’ learning in everyday work within the context of elderly care. The study used a qualitative research approach and was carried out within four Swedish elderly care organisations. A total of 40 first-line managers were interviewed, 10 of whom kept time-use diaries. The theoretical framework is based on a workplace learning perspective originating from theory of situated learning. Situated learning theory includes the concepts of community of practice, legitimate peripheral participation, and membership, which serve as analytical tools to illuminate characteristics of learning from various angles. In addition, the concept of gender has been used to gain a deeper understanding for managers’ workplace learning in the female-dominated elderly care context.The findings showed that managers’ learning happened in a stream of varied tasks and interactions shaped by conditions in the workplace. The managers’ work was characterised by unpredictability and changing circumstances, which meant they continuously had to learn how to handle new situations and expand their repertoire of managerial practices. One common perception among themanagers was the importance of being able to make quick decisions with limited information, and assess the results afterwards. The managers learned how to deal with work situations by either maintaining and modifying current practices or inventing new ones. In addition to these three practices, their learning was affected by different conditions, particularly professional experience, work relationships and organisational conditions. The findings further showed that the managers had to learn to deal with expectations of how they should act in the managerial role based on their gender, and learn to navigate between gender ideals that permeated the female-dominated elderly care environment.Three conclusions were drawn from this study. The first was that managers took great responsibility for their own learning, including what they needed to know and how they would learn it. Despite the fact that they all had access to resources provided by the employer, managers often chose alternative ways to learn, usually by relying on informal networks and close personal relationships. As a result of this self-directed learning, they were able to make decisions that suited their learning needs, and effectively proceed in practice without having to confirm their chosen methods.The second conclusion was that work relationships played a central part in managers’ learning, within both the care work community and the first-line manager community. Work relationships with other first-line managers provided support for learning through, for example, knowledge exchange and joint discussions, as well as emotional support. Work relationships with subordinates were significant for learning, and could result in solutions to complex issues, which could have a direct effect on the daily operation of care work services. Due to the diverse mix of professions, varying interests, and formal positions of authority in the care work community, managers were required to devote considerable time and effort to facilitate collaboration and a shared repertoire. As a result, learning was seen as a stimulating and enjoyable experience, but was also demanding and sometimes boring.The third conclusion was that in the context of the female-dominated elderly care gender operated differently in two communities of practices. Male privilege was still prominent in the care work community, as men were accepted and perceived as legitimate leaders among their subordinates. Female managers instead had to navigate and balance the expectations associated with femininity and the managerial role in this community. However, the female-dominated elderly care context provided female managers with more opportunities to connect with equal peers and establish influential positions, whereas male managers could encounter challenges in gaining access to learning and participating in the first-line manager community.
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| 6. |
- Bruno, Linnéa, 1975-
(författare)
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Ofridstid : Fäders våld, staten och den separerande familjen
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The present thesis explores intersectional and institutional conditions for counteracting domestic violence in the Swedish welfare state. Empirically, the study focuses on professional discourses and practices concerning fathers’ violence against mothers and children in the context of separation, in three domains of practice: 1) Children’s education; 2) Disputes concerning custody, contact and residence; and 3) Welfare benefits such as financial aid. Theoretically, the study draws on feminist political theory and sociology, childhood studies and critical race studies. The empirical material consists of court orders and interviews with staff and victimised mothers. Two main social processes that undermine implementation of children’s rights are identified and discussed: Familialisation and selective repression. The thesis is based on four articles:Article I, (Skolan, familjerätten och barnen) School, family law and children exposed to violence, explores how staff at school and preschool understands their professional task, when in encounters with children in difficulties due to family law proceedings. The results suggest that two competing perspectives shape staff understandings of risks, solutions and violence. When arguing from the child’s rights’ perspective, the staff prioritises children’s safety and participation, while an upbringing perspective tends to construct violence mainly as a problem of order, with disquieting implications for vulnerable children.Article II, (Pedagoger i det sociala uppdragets gränstrakter: Att hantera familjerättsliga processer, hot och våld)Pedagogues in the borderland of their social task: Dealing with family law proceedings, threats and violence, investigates strategies used by preschool and school staff, when encountering gendered conflicts and violence between parents. How do the staff cope with their own and children’s vulnerability? An analytical model of six types of proactive and reactive strategies, ranging from keeping distance to normalisation of own vulnerability, is utilised in the analysis and discussed in relation to organisational and professional circumstances and intersecting social relations of inequality.Article III, Contact and evaluations of violence: An intersectional analysis of Swedish court orders, examines obstacles to implementation of children’s rights in contested parental contact cases in which there are indications of violence. The analysis shows that the contact presumption is strong, and generally overrides protection. This norm applies even where there are convictions or explicit reports of child abuse or domestic violence. In cases with ‘non-Nordic’ fathers however, the contact presumption is less likely to override protection than in cases with ‘Nordic’ fathers.Article IV, Financial oppression and post-separation child positions in Sweden, deals with post-separation child positions in two domains of practice in the Swedish welfare state: Welfare benefits such as financial aid, and child contact. The area of concern is financial oppression in the context of parental separation. Findings suggest that financial abuse in the context of parental separation is a non-question in the domain of welfare benefits, and in the domain of child contact framed as a conflict between equal parties. The age order as a form of domination may be reinforced by the practice of both domains.
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| 7. |
- Crommert, Martin Eriksson, 1974-
(författare)
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On the role of transversus abdominis in trunk motor control
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- All trunk muscles are important contributors to spine stability. However, the deepest abdominal muscle, transversus abdominis (TrA), with its characteristically horizontal fibre orientation seems to serve a unique function in trunk motor control. The main mechanical role of TrA is believed to be to contribute to vertebral alignment during imposed moments on the trunk, executed mainly via either regulating the pressure level within the abdominal cavity and/or transmit forces to the spine via the thoracolumbar fascia. However, the complete function of TrA and what factors affect its activation are still not fully understood. The purpose of the present thesis was to investigate the role of TrA in trunk motor control, specifically in relation to the presence or absence of postural demand on the trunk.The timing and magnitude of TrA activation were investigated, in relation to other trunk muscles, with intramuscular fine-wire electrodes in different loading situations and body positions with varying postural demand.In a side-lying position, with no postural demand of keeping the trunk upright, the activation of TrA was delayed relative the superficial abdominal muscles compared to previous experiments performed in a standing position. The timing and magnitude of activation of TrA did not depend upon the direction of perturbation. In the standing position, different static arm positions revealed that the activation of TrA co-varied with variations in the degree of postural demand on the trunk and also the imposed moments, regardless of moment direction. Finally, a study on rapid arm flexion movements confirmed that TrA is part of the pre-programmed anticipatory response in advance of known perturbations. The activation magnitude of TrA was the same regardless if the arm movement induced flexion or extension moments on the trunk.In conclusion, the activation of TrA is associated with the upright postural demand on the trunk and with balancing imposed moments acting on the spine, regardless their direction. The findings are in support of the beliefs that TrA act as a general, direction non specific, stabilizer of the lumbar spine.
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| 8. |
- Dahlberg, Karuna, 1979-
(författare)
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e-Assessed follow-up of postoperative recovery : developement, evaluation and patient experiences
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The majority of all surgeries are performed as day surgery. After discharge, patients are expected to take responsibility for their postoperative recovery themselves. Recovery Assessment by Phone Points (RAPP) is an e-assessment developed for assessing and providing follow-up on postoperative recovery, which includes the Swedish web-version of the Quality of Recovery questionnaire (SwQoR). It also enables the patient to get in contact with the day surgery unit. The overall aim of this thesis was to further develop and evaluate a systematic follow-up of postoperative recovery using a mobile app in adult persons undergoing day surgery, as well as to describe their experiences of postoperative recovery when using the mobile app. Study I: This study included three steps. Equivalence testing between the paper and app versions of the SwQoR showed agreement (n=69). The feasibility and acceptability evaluation showed that participants (n=63) were positive towards using a mobile phone application during postoperative recovery. Content validity of the SwQoR reduced the original 31 items to 24. Studies II and III: A multicentre, two-group, parallel, single-blind randomized controlled trial including 997 participants was conducted to investigate the effect of e-assessment on postoperative recovery (II) and cost-effectiveness (III) in a RAPP group compared with a control group. The RAPP group reported significantly better quality of postoperative recovery on postoperative days 7 and 14 compared with the control group. Moreover, RAPP may be cost-effective as it provides low-cost care. Study IV: Explored experience of postoperative recovery in participants using a mobile phone app during their postoperative recovery. Qualitative inductive semi-structured interviews (n=18) were performed. Findings showed that feeling safe is important during postoperative recovery. This feeling can be created by patients themselves, but sufficient support and information from health care and next of kin is needed. Overall, this thesis showed positive results for RAPP, suggesting that RAPP is a solution that may benefit patients after day surgery.
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| 9. |
- Eriksson, Anna-Karin, 1979-
(författare)
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Global history or inter|nationalist discourse!? : Unsettling the 'comfort women' issue
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Survivors of the ‘comfort’ system, the state-sponsored regime of military sexual exploitation and a core institution in the expansion of the empire of Japan from 1932 to 1945, continue to go unrecognised almost 80 years past 1945 and 30 years after the breakthrough by human rights activists in 1991. That such a brutal regime of sexual exploitation remains unrecognised by the state is remarkable and merits attention. In this thesis, I suggest that the ‘comfort women’ issue remains stuck in a deadlock that freezes it in the inter-state framing of a status quo. As a result the comfort women, the survivors and supposed protagonists, are rendered as mere tiles in a series of inter-state conflicts between the State of Japan and its neighbours in Northeast Asia as one of the fiercest battlegrounds in this region’s ‘history wars’. My purpose in the thesis is to offer possibilities to rethink the comfort women issue beyond this deadlock. To this end, I (1) identify the dynamics that sustain and reify the deadlock (Paper 1 and Paper 2) and (2) unsettle these dynamics (Paper 3 and Paper 4).
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| 10. |
- Eriksson, Heléne, 1964-
(författare)
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End of Life Stroke Care : perspectives of health-care professionals and family members
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- IntroductionEven though medical improvements have reduced the mortality rates for patients afflicted by stroke, mortality during the first few days at hospital is significant. Today, there is an increasing recognition that the principles of palliative and supportive care are important components of meeting the needs of patients severely afflicted by stroke even in acute settings. However, there is limited knowledge about which factors have an impact on the end-of-life care (EoLC) for these patients or about how these last days of life are experienced from the family members’ perspective.AimThe overall aim of this thesis was to describe the EoLC of patients severely afflicted by stroke and to identify factors impacting upon EoLC for the patients and their family members in Sweden out of various contexts and methods.Design and MethodsThis thesis is based upon four papers employing qualitative, quantitative and mixed-method designs.Paper I is a qualitative study based on focus-group interviews with 41 health-care professionals (HCPs) in different professions related to stroke care at three stroke units. The aim was to study ethical dilemmas, different approaches and what consequences they had among health HCPs; the data was analysed using content analysis. The result inspired the design and conduct of the following studies.Paper II is a quantitative comparative study based on a retrospectively registered questionnaire from the Swedish Registry of Palliative Care (SRPC). Patients dying of stroke (n =1626) were compared with patients dying from cancer (n=1626), according to symptoms, symptom management and communication with the patient and family members during the last week of life. Data was statistically calculated using OR.Paper III is a mixed-method study employing a sequential explanatory design. In the first, quantitative, part, 995 stroke patients who died in hospital were compared with 631 stroke patients who died at nursing homes, according to symptoms, symptom management and communication with the patient and family members during the last week of life. The quantitative data was statistically calculated using OR and the qualitative data was analysed using content analysis. Nine significant differences drawn from the quantitative results regarding care were chosen to be discussed by twelve nurses working in stroke units.Paper IV is a qualitative interview study with the aim to study the family member descriptions of the trajectory from admission to the hospital until their loved one died. A semi-structured interview guide was used, and data was analysed using thematic analyses.ResultsFactors that had an impact on EoLC were consequences related to the difficulties around decision-making about withholding or withdrawing life-sustaining treatment. Non-decisions or not holding to the decision generated communication barriers causing obstacles in inter-professional collaboration and ethical dilemmas within the team (Study I). The absence of a mutual approach to care resulted in underprovided palliation, undignified medical treatment and ambiguity in care, generating feelings of distrust among the family members. The results described in Study I of underprovided palliation were further investigated in Study II. The differences in knowledge about whether symptoms were present or not in patients afflicted by stroke compared to patients with cancer were significant. For example, the HCPs in the stroke group did not know if pain was present nine times more frequently than in the cancer group. These differences in knowledge about whether symptoms were present of not were also identified in Study III. Here, HCPs at the nursing home more often had knowledge about whether a symptom was present in patients dying of stroke or not, compared to HCPs at hospitals. This study also identifies differences in the presence of the symptoms being compared and whether the patient’s suffering was fully relieved. The nurses working at stroke units explained that these differences were a consequence of the stroke unit’s aim (saving lives), no previous relationship to the patient and ambiguity in the evaluation of symptoms. The patient’s altered levels of consciousness increased the difficulties in evaluation. In addition, the hospital setting’s aim increased the risk of prolonged treatment, for example nutrition supplied during the last day of life, and underprovided palliation of for example, pain compared to nursing homes. In Study IV, family members were seeking trust through mutual collaboration and creating relationships with the HCPs. If the family did not feel that their search for trust was taken care of, it generated feelings of distrust allied with anxiety and memories of failing to do the best for their loved one at in the end of life. During the trajectory at the hospital, family members were “seeking trust in chaos”, “seeking clarity when deciding about living or dying” and finally they were “seeking trust in care as a final act of love”.Conclusions:The results of this thesis suggest that the absence of a coherent approach contributes to developing ethical dilemmas within the HCPs. The ambiguity in care had an impact on the quality on EoLC, with an increased risk of unnecessary suffering and questionable symptom management. The prevailing culture at acute-care hospitals affected the HCPs’ attitudes towards EoLC, with attention being predominantly on life-sustaining treatments. There is an increasing recognition of the need for improvement in the PC approach at acute-care hospitals in order to create equal quality of care during end of life, irrespective of the place of death for patients dying of stroke. Furthermore, family members need to feel trust, which is achieved through relationships and collaboration with HCPs. In the striving to accomplish a wholly compensatory care of quality during the trajectory, this thesis can be a source of knowledge and guidance for nurses and for teams at the stroke unit.
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