13 research outputs found
Malnutrition in elder care: qualitative analysis of ethical perceptions of politicians and civil servants
New knowledge about malnutrition in elder care related to ethical responsibility was illuminated by persons holding top positions. Malnutrition was stressed as an important dimension of the elder care quality. Governing at a distance meant having trust in the staff, on the one hand, and discomfort and distrust when confronted with reports of malnutrition, on the other. Distrust was directed at caregivers, because despite the fact that education had been provided, problems reappeared. Discomfort was felt when confronted with examples of poor nutritional care and indicates that the participants experienced failure in their ethical responsibility because the quality of nutritional care was at risk
Ethical challenges related to elder care. High level decision-makers' experiences
Few empirical studies have been found that explore ethical challenges among persons in high public positions that are responsible for elder care. The aim of this paper was to illuminate the meaning of being in ethically difficult situations related to elder care as experienced by high level decision-makers. A phenomenological-hermeneutic method was used to analyse the eighteen interviews conducted with political and civil servant high level decision-makers at the municipality and county council level from two counties in Sweden. The participants worked at a planning and control as well as executive level and had both budget and quality of elder care responsibilities. Both ethical dilemmas and the meaning of being in ethically difficult situations related to elder care were revealed. No differences were seen between the politicians and the civil servants. The ethical dilemmas mostly concerned dealings with extensive care needs and working with a limited budget. The dilemmas were associated with a lack of good care and a lack of agreement concerning care such as vulnerable patients in inappropriate care settings, weaknesses in medical support, dissimilar focuses between the caring systems, justness in the distribution of care and deficient information. Being in ethically difficult situations was challenging. Associated with them were experiences of being exposed, having to be strategic and living with feelings such as aloneness and loneliness, uncertainty, lack of confirmation, the risk of being threatened or becoming a scapegoat and difficult decision avoidance. Our paper provides further insight into the ethical dilemmas and ethical challenges met by high level decision-makers', which is important since the overall responsibility for elder care that is also ethically defensible rests with them. They have power and their decisions affect many stakeholders in elder care. Our results can be used to stimulate discussions between high level decision-makers and health care professionals concerning ways of dealing with ethical issues and the necessity of structures that facilitate dealing with them. Even if the high level decision-makers have learned to live with the ethical challenges that confronted them, it was obvious that they were not free from feelings of uncertainty, frustration and loneliness. Vulnerability was revealed regarding themselves and others. Their feelings of failure indicated that they felt something was at stake for the older adults in elder care and for themselves as well, in that there was the risk that important needs would go unme
Master's level in primary health care education - students' and preceptors' perceptions and experiences of the alteration in the clinical areas
Meeting ethical and nutritional challenges in elder care : The life world and system world of staff and high level decision-makers
The overall aim of the thesis was to describe the issue of malnutrition
and use it as a focal point of interest in elder care. A further aim was
to illuminate how this issue could be addressed focusing on older adults'
integrity and high level decision-makers' reasoning about ethically
difficult situations (I-IV). Older adults, caregivers and high level
decision-makers (HDMs) i.e. elected politicians and civil servants
participated in the studies.
Study I focused on the frequency of underweight, weight loss and related
risk factors among older adults living in 24 sheltered housing units
located in one county. Measurements were obtained from 719 and were
repeated after one year with the 503 still participating (I). Weight
changes in older adults and changes in mealtime routines and environment
were followed after a three month integrity promoting intervention. The
participants were living at two nursing homes, 18 from the intervention
ward (I-ward) and 15 from the control ward (Cward) (II). The HDMs` views
and reasoning regarding malnutrition in elder care were illuminated (III).
Also highlighted were the HDMs' experiences of the meaning of being in
ethically difficult situations related to elder care (IV). Participating
in studies 111-IV were eighteen HDMs from the municipality or county
council level. The inclusion area encompassed two counties (IIV). Methods
used in the studies were: descriptive statistics and logistic regression
(I), descriptive and comparative statistics as well as manifest content
analysis (II), latent content analysis (III) and phenomenological
hermeneutic analysis (IV).
A considerable percentage of the older adults in the sheltered housing
units were underweight or exhibited weight loss. After a year,
significant changes were found such as declined cognitive and functional
capacity, eating dependencies, and chewing and swallowing problems. Risk
factors associated with underweight and weight loss were cognitive and
functional decline, eating dependencies and constipation (I). After the
intervention that included staff training, the meal environment and
routines were changed and weight increases were seen in 13 of 18 older
adults from the I-ward compared with two of 15 from the C-ward. The
individual weight changes correlated significantly to changes in the
intellectual functions. Increased contact with the older adults and a
more pleasant atmosphere was reported (II). The HDMs cited the older
adults' poor health status, caregivers' lack of knowledge and inflexible
routines as possible causes for the malnutrition. They suggested the need
for increased physician intervention, more education and individualised
care. The HDMs placed the responsibility for the issues more with
caregivers and physicians then with the local managements and themselves
(III). Both ethical dilemmas and the meaning of being in ethically
difficult situations related to elder care were revealed by the HDMs (IV).
The dilemmas mostly concerned difficulties of dealing with extensive care
needs with a limited budget. Other aspects included the lack of good care
for the most vulnerable, weaknesses in medical support, dissimilar
focuses between caring systems and justness in the distribution of care.
Being in ethically difficult situations was associated with being
exposed, having to be strategic, feelings of aloneness, loneliness and
uncertainty, lack of confirmation, risk of being threatened or becoming a
scapegoat and avoidance of difficult decisions (IV).
Different levels in a health care system seem to be intertwined with
ethical and nutritional challenges that confront and are associated with
the different assumed roles. The results are reflected in the so called
life world that concerns relationships, the system world that concerns
routines and the governing of goals, and the tension between these two
worlds. Structures that enable dialogues where ethical issues can be
brought up from the different levels and between the different
professionals inside the health care system seem to be important for the
reduction of feelings of distrust and an improvement in elder care
Fewer referrals to Swedish Emergency Departments among nursing home patients with dementia, comprehensive cognitive decline and multicomorbidity.
Pain prevalence among residents living in nursing homes and its association with quality of life and well-being
Background: Pain is common and often more complex to assess among nursing homes residents with cognitive impairments. Thus, more research is needed of different pain assessment methods in elderly care and how these assessments outcomes are related to quality of life, as there mostly should be a negative relationship. There is a risk that pain are under diagnosed among persons with cognitive impairment. Aim: The aim was to describe and compare pain prevalence among nursing home residents (1) using different pain assessment methods (2) in relation to cognitive status and to (3) examine associations between pain and quality of life or well-being. Methods: A cross-sectional correlational design was used, participants were 213 nursing home residents and data were collected through interviews using standardised protocols. Instrument used were Katz index of ADL, Mini-Mental-State-Examination, Quality of Life in Late-Stage Dementia scale, WHO-5 well-being index, Numeric Rating Scale and Doloplus-2 scale. Results: The results showed high pain prevalence, but no significant difference based on cognitive level. Pain classification at the individual level varied somewhat when different instruments are used. The results indicated that use of a single-item proxy-measure for pain tends to show higher pain prevalence and was not statistically significant related to quality of life. The relationship with quality of life was statistically significant when self-rated pain instruments or multi-component observation were used. Conclusions: The study shows that it is difficult to estimate pain in residents living at nursing homes and that it continues to be a challenge to solve. Self-rated pain should be used primarily to assess pain, and a multi-component observation scale for pain should be used when residents are cognitively impaired. Both self-rated pain and multi-component observation also support the well-known link between pain and quality of life. Single-item proxy assessments should only be used in exceptional cases
Referrals to Emergency Departments- The Processes and Factors That Influence Decision-Making among Community Nurses A. Kihlgren et al. Keywords
Abstract The aim of the study was to describe the basis on which municipal care registered nurses (RN) make decisions and their experiences when referring older persons from nursing homes to emergency departments (EDs). RNs in the community are to ensure that older adults receive good care quality in nursing home. This study used a descriptive design with a qualitative content analysis. The analysis of the data from the 13 interviews revealed one theme "Shared responsibilities in the best interests of the older person reduce feelings of insufficiency". The content was formulated, which revealed the RNs' feelings, reasoning and factors influencing them and their actions in the decision-making situation, before the patients were referred to an emergency department. Complex illnesses, non-adapted organizations, considerations about what was good and right in order to meet the older person's needs, taking account of her/his life-world, health, well-being and best interests were reported. Co-worker competencies and open dialogues in the "inner circle" were crucial for the nurses' confidence in the decision. Hesitation to refer was associated with previous negative reactions from ED professionals. The RN sometimes express that they lacked medical knowledge and were uncertain how to judge the acute illness or changes. Access to the "outer circle", i.e. physicians and hospital colleagues, was necessary to counteract feelings of insecurity about referrals. When difficult decisions have to be made, not only medical facts but also relationships are of importance. To strengthen the RNs' and staff members' competence by means of education seems to be important for avoiding unnecessary referrals. Guidelines and work routine need to be more transparent and referrals due to the lack of resources are not only wasteful but can worsen the older persons' health
Referrals to Emergency Departments- The Processes and Factors That Influence Decision-Making among Community Nurses A. Kihlgren et al. Keywords
Abstract The aim of the study was to describe the basis on which municipal care registered nurses (RN) make decisions and their experiences when referring older persons from nursing homes to emergency departments (EDs). RNS' in the community are to ensure that older adults receive good care quality in nursing home. This study used a descriptive design with a qualitative content analysis. The analysis of the data from the 13 interviews revealed one theme "Shared responsibilities in the best interests of the older person reduce feelings of insufficiency". The content was formulated, which revealed the RNs' feelings, reasoning and factors influencing them and their actions in the decision-making situation, before the patients were referred to an emergency department. Complex illnesses, non-adapted organizations, considerations about what was good and right in order to meet the older person's needs, taking account of her/his life-world, health, well-being and best interests were reported. Co-worker competencies and open dialogues in the "inner circle" were crucial for the nurses' confidence in the decision. Hesitation to refer was associated with previous negative reactions from ED professionals. The RN sometimes express that they lacked medical knowledge and were uncertain how to judge the acute illness or changes. Access to the "outer circle", i.e. physicians and hospital colleagues, was necessary to counteract feelings of insecurity about referrals. When difficult decisions have to be made, not only medical facts but also relationships are of importance. To strengthen the RNs' and staff members' competence by means of education seems to be important for avoiding unnecessary referrals. Guidelines and work routine need to be more transparent and referrals due to the lack of resources are not only wasteful but can worsen the older persons' health
Referrals to Emergency Departments: The Process and Factors That Influence Decision-Making among Community Nurses
The aim of the study was to describe the basis on which municipal care registered nurses (RN) make decisions and their experiences when referring older persons from nursing homes to emergency departments (EDs). RNs in the community are to ensure that older adults receive good care quality in nursing home. This study used a descriptive design with a qualitative content analysis. The analysis of the data from the 13 interviews revealed one theme “Shared responsibilities in the best interests of the older person reduce feelings of insufficiency”. The content was formulated, which revealed the RNs’ feelings, reasoning and factors influencing them and their actions in the decision-making situation, before the patients were referred to an emergency department. Complex illnesses, non-adapted organizations, considerations about what was good and right in order to meet the older person’s needs, taking account of her/his life-world, health, well-being and best interests were reported. Co-worker competencies and open dialogues in the “inner circle” were crucial for the nurses’ confidence in the decision. Hesitation to refer was associated with previous negative reactions from ED professionals. The RN sometimes express that they lacked medical knowledge and were uncertain how to judge the acute illness or changes. Access to the “outer circle”, i.e. physicians and hospital colleagues, was necessary to counteract feelings of insecurity about referrals. When difficult decisions have to be made, not only medical facts but also relationships are of importance. To strengthen the RNs’ and staff members’ competence by means of education seems to be important for avoiding unnecessary referrals. Guidelines and work routine need to be more transparent and referrals due to the lack of resources are not only wasteful but can worsen the older persons’ health.Article ID: 45320. The authors wish to express their gratitude to the Ministry of Health and Social Affairs and the Swedish Association of Local Authorities in Gävleborg for grants.</p