Exploring care for older people : district nurses’ experiences and clinical practice

Background and aim: The health care system needs to prepare in order to provide highquality care to a growing older population. In Sweden, much primary health care for older people is the responsibility of district nurses (DNs), but research into DNs’ clinical care has not been extensive. The general aim of this thesis was therefore to explore the clinical care DNs provide to older people and DNs’ experiences of this care, focusing on preventive home visits (PHVs), medication management, and leg ulcer care. Material and methods: The thesis includes five studies. Study I used qualitative content analysis to analyze data from group interviews with 20 DNs about their experiences of PHVs. In Study II, DNs used the Safe Medication Assessment (SMA) tool in PHVs with 113 people to identify factors related to unsafe medication management and to describe interventions used to improve the safety of medication management. Study III employed data from the Swedish Prescribed Drug Register on 671,940 community-dwelling older people to examine the extent and quality oftheir drug use. In Study IV, the electronic records of 97 patients before and 96 after the intervention were used to evaluate DNs' leg ulcer management. In Study V, grounded theory method was used to collect and analyze data from group interviews with 30 DNs about providing leg ulcer care in accordance with guidelines. Results: Study I found facilitators of and barriers to a successful health dialogue in the PHV. Three main themes illustrated professional dilemmas in the health dialogue that the DNs had to resolve to achieve the purpose of the PHV. In Study II, DNs found several factors related to unsafe medication management when they used the SMA during PHVs. DNs intervened to improve medication management in more than two-thirds of the visits. Study III found that the prevalence of most drug groups and ofinappropriate drug use increased with age. Polypharmacy and use of potentially inappropriate medications were already prevalent in 75- year-olds. Study IV found that nurses' documentation ofleg ulcer management was sparse and far from consistent with clinical guidelines. Study V resulted in a theoretical model that illustrates how DNs balance compensating, motivating, and compromising strategies to follow clinical guidelines as far as possible and provide leg ulcer care that is good enough. Conclusions: DNs experience facilitators ofand barriers to health dialogues during PHVs and must balance a personal and a professional approach, a task-oriented and person-oriented approach, and a salutogenic and a pathogenic approach. The proportion of people who use drugs in most drug groups and who take inappropriate drugs increases with age. Using the SMA tool in PHVs may help improve the safety of medication management in older people and may be appropriate at age 75 and age 80. DNs cannot always follow guidelines but try to adhere to a treatment plan that is acceptable to patient and that hopefully can lead to a healed leg ulcer

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT.

BACKGROUND: Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression. OBJECTIVES: (1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT). DESIGN: Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation. INTERVENTION DEVELOPMENT: Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation. FEASIBILITY RCT: Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU). SETTING: Community settings in London and Hertfordshire, UK. PARTICIPANTS: A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty. MAIN OUTCOME MEASURES: Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs. RESULTS: We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding. CONCLUSIONS: Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible. FUTURE WORK: A large, definitive RCT of the HomeHealth service is warranted. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information

Det är ju jag som bestämmer om jag ska dricka eller inte- En kvantitativ studie av ungdomars alkoholbruk utifrån grupp och klass

Syfte och problemområde: Vårt syfte med uppsatsen är att undersöka gymnasieelevers förhållningssätt till alkohol. Vi vill även undersöka hur klasstillhörighet och kamratgrupper påverkar enskilda individer i sitt alkoholbruk. Metod och material: Vi har använt oss av en kvantitativ metod och lämnat ut 100 enkäter på en gymnasieskola i Skövde. Vi har studerat tidigare forskning inom området, i form av avhandlingar, propositioner, vetenskapliga artiklar och rapporter samt litteratur. Vi använder oss av tre begrepp utifrån socialpsykologisk teori (social identitet, roll och grupp) för att förstå och förklara resultatet av vår studie. Resultat: Vårt övergripande resultat är att gymnasieungdomar i stor utsträckning dricker alkohol. Ungdomarna själva verkar vara omedvetna om en eventuell påverkan från kompisar när det gäller deras alkoholkonsumtion, men både teorin och den tidigare forskningen visar att detta grupptryck borde vara starkt. Ungdomarna i vår studie säger trots allt att de tror att jämnåriga dricker mer alkohol tillsammans med kompisar än om de dricker ensamma. Ungdomars planer på att studera vidare påverkar hur mycket alkohol de konsumerar, men detta resultat visade sig inte vara helt tillförlitligt. Den vanligaste anledningen till att dricka alkohol visade sig vara för att det är gott och för att ha roligt, de flesta drack alkohol på hemmafester och de vanligast förekommande alkoholsorterna var öl, cider, sprit och alkoläsk. Fler ungdomar än väntat har druckit alkohol ensamma och det har funnits olika skäl till detta

Leaders’ behaviour in knowledge sharing groups

Effectiveness and performance in groups are largely dependent on how group members manage to share their individual knowledge with each other. When group members share and combine their individual knowledge at an optimal level in order to find new solutions, they achieve knowledge integration. In this thesis, we examine how group leaders act to encourage knowledge integration. An observational study was used to evaluate how leaders in three different groups act when solving a group task. We focused on the leaders’ actions in relation to group behaviours that would promote and prevent knowledge integration. With support from theories, we created a behaviour model to help us identify a set of relevant behaviours. We also supported our analysis with leadership theories. The results showed us that leaders’ actions were to a great extent dependent on the current followership and dynamics of each group. Another result was that group members who were familiar with one another before entering the group, had more difficulties in adopting behaviours that would promote knowledge integration. This meant that the leader did not come to terms with the leadership in order to promote knowledge integration.I en alltmer komplex omvärld ökar behovet av samarbetsskicklighet. Kunskapsintegration anses vara ett viktigt fenomen när grupper samarbetar för att prestera bättre och arbeta effektivt vid mötet av nya behov och problem. Grupper uppnår kunskapsintegration då deltagarna på en optimal nivå utbyter kunskap med varandra, eftersom gruppen då utnyttjar sin fulla kunskapspotential till att finna nya lösningar. Den rådande gruppdynamiken blir därmed avgörande för gruppens prestationsförmåga. En person som har ett särskilt ansvar för gruppens kollektiva arbete är gruppledaren. Huruvida ledare faktiskt agerar för att främja kunskapsintegration är därför centralt i den här uppsatsen. Syftet med studien är att undersöka ledarageranden i förhållande till de gruppbeteenden som kan antas främja eller förhindra kunskapsintegration. Vi har valt att fokusera på arbetsprocessen i en undersökning som går ut på att observera ledaren för en grupp som tilldelas en uppgift, där deltagarna tillsammans ska lösa ett problem. Vi observerade tre grupper på sex personer vardera där en av deltagarna utsågs till ledare genom lottdragning. Processerna dokumenterades med hjälp av filminspelning. Vi har använt oss av teorier för att kunna identifiera gruppbeteenden som kan antas främja och förhindra kunskapsintegration. Med hjälp av teorierna skapade vi en egen beteendetabell att ta stöd av i våra observationer och i vår analys. För att ytterligare undersöka ledarens roll i observationsgrupperna har vi använt oss av ledarskapsteorier. I analysen gick vi först igenom händelseförloppen i filmerna, för att sedan kunna urskilja de beteenden som stämde överens med vår beteendetabell. Därefter specificerade vi ledarens ageranden i förhållande till dessa. Resultaten av studien visade att ledarskapet tycks anpassa sig mycket utefter följarskapet och därmed dynamiken i gruppen och därför identifierade vi inga gemensamma nämnare för ledarageranden i grupperna. Följarskapet i grupperna varierade stort och därför agerade också ledarna på olika sätt. Resultaten gav oss även en oförmodad slutsats som visade att grupper där fler deltagare känner till varandra sedan tidigare hade svårare att anta beteenden som kan antas främja kunskapsintegration. Detta ledde därför till att ledarens agerande blev svårt att bedöma

Leaders’ behaviour in knowledge sharing groups

Effectiveness and performance in groups are largely dependent on how group members manage to share their individual knowledge with each other. When group members share and combine their individual knowledge at an optimal level in order to find new solutions, they achieve knowledge integration. In this thesis, we examine how group leaders act to encourage knowledge integration. An observational study was used to evaluate how leaders in three different groups act when solving a group task. We focused on the leaders’ actions in relation to group behaviours that would promote and prevent knowledge integration. With support from theories, we created a behaviour model to help us identify a set of relevant behaviours. We also supported our analysis with leadership theories. The results showed us that leaders’ actions were to a great extent dependent on the current followership and dynamics of each group. Another result was that group members who were familiar with one another before entering the group, had more difficulties in adopting behaviours that would promote knowledge integration. This meant that the leader did not come to terms with the leadership in order to promote knowledge integration.I en alltmer komplex omvärld ökar behovet av samarbetsskicklighet. Kunskapsintegration anses vara ett viktigt fenomen när grupper samarbetar för att prestera bättre och arbeta effektivt vid mötet av nya behov och problem. Grupper uppnår kunskapsintegration då deltagarna på en optimal nivå utbyter kunskap med varandra, eftersom gruppen då utnyttjar sin fulla kunskapspotential till att finna nya lösningar. Den rådande gruppdynamiken blir därmed avgörande för gruppens prestationsförmåga. En person som har ett särskilt ansvar för gruppens kollektiva arbete är gruppledaren. Huruvida ledare faktiskt agerar för att främja kunskapsintegration är därför centralt i den här uppsatsen. Syftet med studien är att undersöka ledarageranden i förhållande till de gruppbeteenden som kan antas främja eller förhindra kunskapsintegration. Vi har valt att fokusera på arbetsprocessen i en undersökning som går ut på att observera ledaren för en grupp som tilldelas en uppgift, där deltagarna tillsammans ska lösa ett problem. Vi observerade tre grupper på sex personer vardera där en av deltagarna utsågs till ledare genom lottdragning. Processerna dokumenterades med hjälp av filminspelning. Vi har använt oss av teorier för att kunna identifiera gruppbeteenden som kan antas främja och förhindra kunskapsintegration. Med hjälp av teorierna skapade vi en egen beteendetabell att ta stöd av i våra observationer och i vår analys. För att ytterligare undersöka ledarens roll i observationsgrupperna har vi använt oss av ledarskapsteorier. I analysen gick vi först igenom händelseförloppen i filmerna, för att sedan kunna urskilja de beteenden som stämde överens med vår beteendetabell. Därefter specificerade vi ledarens ageranden i förhållande till dessa. Resultaten av studien visade att ledarskapet tycks anpassa sig mycket utefter följarskapet och därmed dynamiken i gruppen och därför identifierade vi inga gemensamma nämnare för ledarageranden i grupperna. Följarskapet i grupperna varierade stort och därför agerade också ledarna på olika sätt. Resultaten gav oss även en oförmodad slutsats som visade att grupper där fler deltagare känner till varandra sedan tidigare hade svårare att anta beteenden som kan antas främja kunskapsintegration. Detta ledde därför till att ledarens agerande blev svårt att bedöma

District nurses’ experiences of caring for leg ulcers in accordance with clinical guidelines: a grounded theory study

This qualitative study used the grounded theory method to investigate district nurses’ experiences of caring for leg ulcers in accordance with clinical guidelines at seven primary health care centres in Stockholm, Sweden. Group interviews were conducted with 30 nurses. The results describe how district nurses strive to stay on track in order to follow clinical guidelines and remain motivated despite prolonged wound treatment and feelings of hopelessness. Three main obstacles to following the guidelines were found. District nurses used compensating strategies so the obstacles would not lead to negative consequences. If the compensating strategies were insufficient, perceived prolonged wound treatment and feelings of hopelessness could result. District nurses then used motivating strategies to overcome these feelings of hopelessness. Sometimes, despite the motivating strategies, treatment in accordance with guidelines could not be achieved. With some patients, district nurses had to compromise and follow the guidelines as far as possible