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Att fokusera på "varandet" i en värld av görande: stöd till personalen i ett palliativt förhållningssätt vid vård- och omsorgsboende för äldre
Kristianstad University, School of Health and Society, Avdelningen för Hälsovetenskap.ORCID iD: 0000-0002-7790-6906
2013 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
To focus on "being" in a world of doing : support to nurse assistants in applying a palliative care approach in residential care for older people (English)
Abstract [en]

The aim of this thesis was to study nurse assistants’ experience of palliative care and to investigate how an intervention with a focus on a palliative care approach in residential care facilities influenced the nurse assistants and their work situation. The thesis is based on two qualitative and two quantitative studies, focusing on nurse assistants working at residential care facilities for older people. The qualitative studies were based on focus-group interviews before the intervention (I) and individual interviews after the intervention (IV). The quantitative studies (II, III) were based on a questionnaire, including several measurements, that was answered pre-, and post- intervention. The intervention consisted of study circles with nurse assistants, and workshops together with their leaders, focusing on improvement work. A total of 75 nurse assistants participated in the intervention and answered the questionnaire at baseline and at two follow-ups, in comparison with 110 nurse assistants who served as controls. The results show that the nurse assistants experienced that it was difficult to focus on “being”, i.e. on relationship aspects in their work, since the main discourse in residential care focused on “doing”, i.e. on task oriented aspects. Palliative care was described as something that was only applied during a short and defined phase, namely the very last days of the residents’ life. The results also show that nurse assistants experienced difficulties facing emotional and existential issues with regards to both the residents and their relatives (I). The results of study I were, in turn, used as a basis for the development of the intervention. The evaluation of the intervention showed that the nurse assistants, after the intervention, had increased their focus on the residents’ situation and to a greater extent stated that they focused on the residents’ life stories and on aspects that brought meaning to their lives (III). The nurse assistants also stated that they experienced less criticism from their superiors as well as from the residents after the intervention (II). However, the evaluation also showed that the nurse assistants had a more negative view of the leadership (II), were more critical to the medical and the nursing care (III), and that their job satisfaction had decreased (II) after the intervention. Interviews after the intervention showed that they, as a result of the intervention, had not only gained increased insight into their own significance in their encounter with residents and their relatives, but also an increased awareness of the needs of the residents and their relatives. The intervention also contributed to an increased openness in the workgroup. However, the nurse assistants also expressed frustration over barriers, primarily in the form of a lack of resources and limited leadership (IV), standing in the way of the implementation of changes. The results indicate that the nurse assistants, through discussions and reflections over praxis in their ordinary work group, developed an increased awareness about, and focus on “being”, i.e. on relationship aspects. However, it would seem that essential prerequisites, such as support from the leaders and sufficient resources for working in line with a palliative care approach, were not provided. When implementing a palliative care approach in residential care facilities, more focus on support to the leaders is needed in order to maintain sustainable changes.

Place, publisher, year, edition, pages
Lund: Institutionen för hälsa, vård och samhälle, Medicinska fakulteten, Lunds universitet , 2013. , 96 p.
Series
Lund University, Faculty of Medicine doctoral dissertation series, ISSN 1652-8220 ; 2013:25
Keyword [sv]
palliativt förhållningssätt, Stöd, Lärande, Intervention, Undersköterskor, Vårdbiträde, Personal, Särskilt boende, Arbetstillfredställelse, Påfrestning, Vårdkvalitet, Personcentrerad vård, Vårdklimat
National Category
Nursing
Identifiers
URN: urn:nbn:se:hkr:diva-11206Libris ID: 13921646ISBN: 978-91-87189-94-4 (print)OAI: oai:DiVA.org:hkr-11206DiVA: diva2:659820
Available from: 2013-10-29 Created: 2013-10-28 Last updated: 2015-01-27Bibliographically approved
List of papers
1. Having to focus on doing rather than being: nurse assistants' experience of palliative care in municipal residential care settings
Open this publication in new window or tab >>Having to focus on doing rather than being: nurse assistants' experience of palliative care in municipal residential care settings
2012 (English)In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 49, no 4, 455-464 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Palliative care should be provided, irrespective of setting to all patients facing a life-threatening illness and to their families. The situation and needs of older people differ from those of younger people since they often have several co-existing diseases and health complaints. This implies an extensive need for care and for longer periods of palliative care. The main providers of palliative care for older people are nurse assistants, who are also those with the shortest education. AIM: The aim of this study was to illuminate nurse assistants' experience of palliative care for older people in residential care. DESIGN: The study had an explorative, descriptive design. SETTINGS: Thirteen residential care units in three different districts in a large city in southern Sweden. PARTICIPANTS: Twenty-five nurse assistants selected to represent variations in age, gender workplace and work experience. METHODS: Data were collected from six focus-group interviews and subjected to content analysis to gain an understanding of the phenomenon. RESULTS: The nurse assistants described palliative care as a contrast to the everyday care they performed in that they had a legitimate possibility to provide the care needed and a clear assignment in relation to relatives. Palliative care also meant having to face death and dying while feeling simultaneous that it was unnatural to talk about death and having to deal with their own emotions. They emphasised that they were in need of support and experienced leadership as invisible and opaque, but gained strength from being recognized. CONCLUSION: In order to support nurse assistants in providing high quality end-of-life care, more focus is needed on the trajectory of older peoples' dying, on the importance of involving relatives throughout the period of care provision, and on support when encountering death and dying. There is also a need for engaged care leaders, both registered nurses and managers, to recognize the work of nurse assistants and to support care provision for older people within the framework of palliative care philosophy.

Keyword
Focus group, Frail elderly, Nursing assistants, Nursing homes, Palliative care, Support
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hkr:diva-8879 (URN)10.1016/j.ijnurstu.2011.10.016 (DOI)000302980200010 ()22079261 (PubMedID)
Funder
Vårdal Foundation
Available from: 2012-01-12 Created: 2012-01-12 Last updated: 2017-05-12Bibliographically approved
2. Applying a palliative care approach in residential care: effects on nurse assistants' work situation
Open this publication in new window or tab >>Applying a palliative care approach in residential care: effects on nurse assistants' work situation
2015 (English)In: Palliative & Supportive Care, ISSN 1478-9515, E-ISSN 1478-9523, Vol. 13, no 3, 543-553 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim was to investigate the effects of an intervention that applies a palliative care approach in residential care upon nurse assistants' level of strain, job satisfaction, and view of leadership.

Method: A quasi-experimental, pretest and posttest design was used. Study circles with workshops involving nurse assistants (n = 75) and their superiors (n = 9) focusing on emotional and existential issues in palliative care were evaluated using a questionnaire answered by the nurse assistants at baseline (November 2009), post-intervention (May 2010), and six-month follow-up (November 2010) in comparison with controls (n = 110).

Results: Directly after the intervention, the job satisfaction of the nurse assistants decreased and they perceived the leadership more negatively than before the intervention. Six months later, strain as a result of criticism from residents and their superiors and having difficulty in balancing emotional involvement had decreased.

Significance of results: The intervention initially seemed to decrease the well-being of the nurse assistants, which could be the result of their increased awareness of the residents' and relatives' needs, in combination with limited support. More emphasis should be placed on the role of leadership when implementing changes in practice.

Keyword
Palliative care approach intervention, Long-term care, Job satisfaction, Strain, Leadership
National Category
Nursing
Identifiers
urn:nbn:se:hkr:diva-11205 (URN)10.1017/S1478951513000783 (DOI)000356539900016 ()24138938 (PubMedID)
Available from: 2013-10-28 Created: 2013-10-27 Last updated: 2017-12-06Bibliographically approved
3. Applying a palliative care approach in residential care: effects on nurse assistants' experiences of care provision and caring climate
Open this publication in new window or tab >>Applying a palliative care approach in residential care: effects on nurse assistants' experiences of care provision and caring climate
2014 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 28, no 4, 830-841 p.Article in journal (Refereed) Published
Abstract [en]

Background

A palliative care approach aims to integrate psychosocial and existential as well as relationship aspects in the care and is an approach that can be used in residential care. Nurse assistants are the ones who are closest to the residents but have limited prerequisites for working in accordance with the palliative care approach. We aimed to investigate the effects on nurse assistants' experiences of care provision and the caring climate of an intervention applying a palliative care approach in residential care.

Methods

An intervention involving nurse assistants (n = 75) and their leaders (n = 9), in comparison with controls (n = 110), was evaluated using a questionnaire at three points in time.

Results

In the intervention group, positive effects were seen concerning the nurse assistants' reports of the care provision in that they focused more on the residents' stories about their lives and on communicating with the residents about what gave meaning to their lives. Also, negative effects were seen when the nurse assistants rated that the residents' needs for medical and nursing care had not been met at the facility directly after the intervention. No effects were seen concerning the caring climate or the prerequisites of providing more person-centred care.

Conclusion

The intervention seemed to have encouraged the nurse assistants to focus on relationship aspects with the residents. So as not to jeopardise the NAs' well-being and to support NAs in keeping themselves involved in existential issues, their support most certainly needs to be continuous and ongoing. However, in spite of the leaders' involvement, the intervention was not sufficient for changing the organisational prerequisites for more person-centred care.

Keyword
intervention, palliative care, caring, longterm care, nurse assistants, quality of care, person-centred care, caring climate
National Category
Nursing
Identifiers
urn:nbn:se:hkr:diva-11209 (URN)10.1111/scs.12117 (DOI)000345314000024 ()24494588 (PubMedID)
Available from: 2013-10-29 Created: 2013-10-29 Last updated: 2017-12-06Bibliographically approved
4. Nurse assistants’ experience of an intervention focused on a palliative care approach for older people in residential care
Open this publication in new window or tab >>Nurse assistants’ experience of an intervention focused on a palliative care approach for older people in residential care
2012 (English)In: International Journal of Older People Nursing, ISSN 1748-3735, E-ISSN 1748-3743, Vol. 9, no 2, 140-150 p.Article in journal (Refereed) Published
Abstract [en]

Background.  Nurse assistants working in residential care facilities need support to ensure that they provide high-quality care for the residents and support for relatives, from admission to bereavement.

Aim.  The aim was to describe the nurse assistants’ experience of how an intervention with a palliative care approach, had influenced them in their work in residential care for older people.

Participants.  Fourteen nurse assistants working in three different municipal residential care facilities.

Methods.  Data were collected by means of semi-structured individual interviews following an intervention consisting of study circles combined with workshops. The data were analysed using content analysis.

Result.  The nurse assistants felt that, through the intervention, they had gained insight into their understanding of the importance of quality of care. This included an increased awareness of, and respect for, residents’ and relatives’ needs, and an increased understanding of the importance of the outcome of encounters with residents and their relatives. After the intervention, they also felt there was increased openness and understanding between colleagues. However, the nurse assistants also expressed frustration over obstacles to implementing a palliative care approach, such as lack of resources and supportive leadership.

Conclusion.  The nurse assistants felt that the intervention was positive and encouraged them to provide more person-centred care within the framework of a palliative care approach. Although the intervention was intended to involve and support the management, it was not sufficient. Nurse assistants described lack of resources and supportive leadership. There is, therefore, a need to place greater emphasis on leadership and their support of nurse assistants so that they can provide high-quality care.

Implications for practice.  To support nurse assistants in the provision of care, clear leadership and opportunities to discuss and reflect on issues associated with care, including systematic improvement work in practice, appear to be essential to ensure high-quality care.

Keyword
intervention, nurse assistants, older people, qualitative study, residential care, support
National Category
Nursing
Identifiers
urn:nbn:se:hkr:diva-9712 (URN)10.1111/j.1748-3743.2012.00343.x (DOI)22928728 (PubMedID)
Available from: 2012-09-17 Created: 2012-09-17 Last updated: 2017-12-07Bibliographically approved

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