"Being the main character but not always involved in one's own care transition" - a qualitative descriptive study of older adults' experiences of being discharged from in-patient care to home.

BACKGROUND: The growing number of older adults with chronic diseases challenges already strained healthcare systems. Fragmented systems make transitions between healthcare settings demanding, posing risks during transitions from in-patient care to home. Despite efforts to make healthcare person-centered during care transitions, previous research indicates that these ambitions are not yet achieved. Therefore, there is a need to examine whether recent initiatives have positively influenced older adults' experiences of transitions from in-patient care to home. This study aimed to describe older adults' experiences of being discharged from in-patient care to home. METHODS: This study had a qualitative descriptive design. Individual interviews were conducted in January-June 2022 with 17 older Swedish adults with chronic diseases and needing coordinated care transitions from in-patient care to home. Data were analyzed using inductive qualitative content analysis. RESULTS: The findings indicate that despite being the supposed main character, the older adult is not always involved in the planning and decision-making of their own care transition, often having poor insight and involvement in, and impact on, these aspects. This leads to an experience of mismatch between actual needs and the expectations of planned support after discharge. CONCLUSIONS: The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making.

Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study.

BACKGROUND: Chronic diseases are increasing worldwide, and the complexity of disease management is putting new demands on safe healthcare. Telemonitoring technology has the potential to improve self-care management with the support of healthcare professionals for people with chronic diseases living at home. Patient safety threats related to telemonitoring and how they may affect patients' and healthcare professionals' sense of security need attention. This study aimed to explore patients' and healthcare professionals' experiences of safety and sense of security when using telemonitoring of chronic conditions at home. METHODS: Semi-structured interviews were conducted with twenty patients and nine healthcare professionals (nurses and physicians), recruited from four primary healthcare centers and one medical department in a region in southern Sweden using telemonitoring service for chronic conditions in home healthcare. RESULTS: The main theme was that experiences of safety and a sense of security were intertwined and relied on patients´ and healthcare professionals´ mutual engagement in telemonitoring and managing symptoms together. Telemonitoring was perceived to increase symptom awareness and promote early detection of deterioration promoting patient safety. A sense of security emerged through having someone keeping track of symptoms and comprised aspects of availability, shared responsibility, technical confidence, and empowering patients in self-management. The meeting with technology changed healthcare professionals' work processes, and patients' daily routines, creating patient safety risks if combined with low health- and digital literacy and a naïve reliance on technology. Empowering patients' self-management ability and improving shared understanding of the patient's health status and symptom management were prerequisites for safe care and the patient´s sense of security. CONCLUSIONS: Telemonitoring chronic conditions in the homecare context can promote a sense of security when care is co-created in a mutual understanding and responsibility. Attentiveness to the patient's health literacy, symptom management, and health-related safety behavior when using eHealth technology may enlighten and mitigate latent patient safety risks. A systems approach indicates that patient safety risks related to telemonitoring are not only associated with the patient's and healthcare professionals functioning and behavior or the human-technology interaction. Mitigating patient safety risks are likely also dependent on the complex management of home health and social care service.

Unfolding alignment - How top management work to align demand and capacity: an ethnographic study of resilience in a Swedish healthcare region.

BACKGROUND: Resilient healthcare organizations maintain critical functions and high-quality care under varying conditions. While previous research has focused on the activities of frontline healthcare professionals working at the "sharp end" of care, less attention has been paid to managers at the top management level. More knowledge is needed to fully understand how the managers align demand and capacity at the "blunt end" of care. Therefore, this study aimed to explore how top managers work to align demand and capacity in a healthcare region in Sweden. METHODS: Observations of management team meetings, interviews, and conversations were conducted with top managers responsible for healthcare in one of Sweden's 21 regions. Data collection used an ethnographic approach. Data were analyzed using qualitative reflexive thematic analysis. RESULTS: The data showed how alignment work was done through active reflection that built on past experiences and on structures built into the organization at the same time as taking future potential outcomes and consequences into account. In addition to collaborative, preventive, supportive, and contextualizing work, which was conducted in the present, a general approach permeated the organization, which enabled connecting actions, i.e., different forms of alignment work, occurring at different points in time, and connecting different types of knowledge across organizational borders and stakeholders. CONCLUSION: This study explored how top managers work to align demand and capacity in a healthcare region in Sweden. It was shown how four categories of work; collaborative, preventive, supportive and contextualization work, together with a general approach; focusing on opportunities, building on a stable past and taking a reflective stance, constitute alignment in practice. More; the alignment work was done in the here and now, with both the past and future in mind. The ability to take action to benefit the whole is a possibility and a responsibility for top management. In the region studied, this was done by aligning demands with capacity based on past experiences and focusing on the available opportunities to connect knowledge needed within and across organizational borders.

Health care professionals' experiences of how an eHealth application can function as a value-creating resource - a qualitative interview study.

BACKGROUND: The number of patients with one or more chronic conditions is increasing globally. One strategy to achieve more sustainable care for these patients is by implementing use of home-based eHealth applications. Such services support patients to take on a more active role as value-creating co-producers of their own care, in collaboration with health care professionals. Health care professionals have a key role in the value creation process, but little is known about value formation within eHealth interactions, especially from their perspective. Therefore, this study aimed to provide a deeper understanding of how an eHealth application can function as a value-creating resource from the perspective of health care professionals. METHODS: Semi-structured interviews were conducted with thirteen health care professionals (nurses, physicians and first-line managers). Qualitative content analysis was used to analyze the interviews. RESULTS: The findings indicate that value formation processes are strongly influenced by the organizational preconditions and by the usability and functionality of technology. The experiences of the health care professionals indicated that value was conceptualized in dimensions of meaningfulness, building of relationships, building safety and feelings of trust. Although these dimensions were mainly expressed in a positive way, such as perceived improvement of medical care, accessibility and continuity, they also had a negative side that caused value destruction. This was primarily due to patient difficulties in using the application or making measurements. Subsequent efforts at value recovery resulted in value creation, but were often time-consuming for the professionals. CONCLUSIONS: This study contributes by extending conceptualizations of value to the role of health care professionals and by highlighting technology as sometimes facilitating and sometimes hampering value formation processes. The findings indicate that the eHealth application was a value-creating resource, facilitating proactive communication and supporting patients' engagement and control over their self-care. However, for the application to become a more valuable resource in practice and counteract inequity in care, it needs to be further developed to be adapted to the needs and preconditions of patients.

Staff Working Life and Older Persons' Satisfaction With Care: A Multilevel, Correlational Design.

BACKGROUND: The importance of staff working life for staff well-being has been demonstrated in several studies; less research has focused on staff working life and older persons' satisfaction with care. PURPOSE: The study aim was to study relationships between 1) staff assessments of their structural conditions/empowerment in elderly care, psychological empowerment, and job satisfaction and (2) older persons' satisfaction with care. METHODS: A multilevel, cross-sectional, and correlational design was applied using questionnaire data on working life (1021 staff members) and unit-level data (40 elderly care units) on older persons' satisfaction with care. RESULTS: Statistically significant relationships were found between all 3 working life variables and older persons' satisfaction with care. Furthermore, the results revealed an indirect/mediating effect of job satisfaction between structural empowerment and satisfaction with care, but not for psychological empowerment. CONCLUSIONS: Staff structural empowerment, psychological empowerment, and job satisfaction are linked to older persons' satisfaction with care.

First-line managers dealing with different management approaches.

PURPOSE: The purpose of this paper is to contribute new knowledge about how first line managers (FLMs) in elderly care perceive their situation, with a focus on differences in management approaches at the intersection of the central and local parts of the organization. DESIGN/METHODOLOGY/APPROACH: The present study has a qualitative approach and is part of a larger project on FLMs in elderly care. The results presented here are based on a secondary analysis of 15 of the total of 28 interviews carried out in the project. FINDINGS: The main results are twofold: the majority of FLMs perceived differences in management approaches between local and central management; the differences caused some struggle because FLMs perceived that the management system did not support the differences. The two main aspects that caused the FLMs to struggle were differences in the foci of the management levels and difficulties in influencing the conditions of management. ORIGINALITY/VALUE: The results contribute to the debate on what aspects are important to sustainable management of elderly care. It is common knowledge that FLMs have a complex position, intermediate to the central, upper level management and their subordinates at the local level - levels with different foci and interests. The study contributes new knowledge about what these differences consist of and the dilemmas they cause and offers suggestions as to what can be done to reduce both energy waste and the risk of low job satisfaction.

How do first-line managers in elderly care experience their work situation from a structural and psychological empowerment perspective? An interview study.

BACKGROUND: The work situation for first-line managers in elderly care is complex and challenging. Little is known about these managers' work situation from a structural and psychological empowerment perspective. AIM: To describe first-line managers' experiences of their work situation in elderly care from a structural and psychological empowerment perspective. METHOD: Interviews from 14 female first-line managers were analysed using qualitative content analysis. RESULTS: The theme described the managers' work situation as "It's not easy, but it's worth it." In the four subthemes, the managers described their work in terms of "Enjoying a meaningful job," "A complex and demanding responsibility that allows great authority within set boundaries," "Supported by other persons, organisational preconditions and confidence in their own abilities" and "Lacking organisational preconditions, but developing strategies for dealing with the situations." CONCLUSION: The managers described having various amounts of access to structural empowerment and experienced a feeling of meaning, competence, self-determination and impact, that is, psychological empowerment in their work. IMPLICATIONS FOR NURSING MANAGEMENT: It is vital that first-line managers have access to organisational support. Therefore, upper management and first-line managers need to engage in continuous dialogue to customize the support given to each first-line manager.

Empowerment and performance of managers and subordinates in elderly care: A longitudinal and multilevel study.

AIM: To investigate relationships between first-line managers' ratings of structural and psychological empowerment, and the subordinates' ratings of structural empowerment, as well as their ratings of the managers' leadership-management performance. BACKGROUND: Work situations in elderly care are complex. To date, few studies have used a longitudinal, correlational and multilevel design to study the working life of subordinates and managers. METHOD: In five Swedish municipalities, questionnaires were answered twice during 2010-12 by 56 first-line managers and 769 subordinates working in nursing homes or home-help services. RESULTS: First-line managers' empowerment at Time 1 partially predicted subordinate's structural empowerment and ratings of their managers' leadership-management performance at Time 2. Changes over time partially revealed that the more access managers had to structural empowerment, i.e. increase over time, the higher the ratings were for structural empowerment and managerial leadership-management performance among subordinates. CONCLUSIONS: Findings strengthen research and theoretical suggestions linking first-line managers' structural empowerment to their subordinates' structural empowerment and ratings of their manager's leadership-management performance. IMPLICATIONS FOR NURSING MANAGEMENT: Managers with high access to structural empowerment are more likely to provide subordinates access to structural empowerment.

A longitudinal study of working life among first-line managers in the care of older adults.

AIM: To study whether the number of subordinates plays a role in first-line managers' and subordinates' ratings of empowerment, stress symptoms, and leadership-management performance. The aim was also to study relationships between managers' empowerment and stress symptoms and leadership-management performance. METHODS: A longitudinal and correlational design was used. All first-line managers (n=98) and their subordinates (n=2085) working in the care of older adults in five municipalities were approached. RESULTS: With fewer (≤30) subordinates per manager, there were higher ratings of structural empowerment among managers and subordinates and lower stress symptoms among subordinates, than with ≥31 subordinates. Furthermore, structural empowerment was related to the managers' stress symptoms and leadership-management performance, mediated through psychological empowerment. Moreover, structural empowerment can control/adjust for large numbers of subordinates in relation to stress symptoms. CONCLUSION: The higher FLMs rated their access to empowerment, the lower stress symptoms and higher leadership-management performance they rated over time.

Male first-line managers' experiences of the work situation in elderly care: an empowerment perspective.

AIM: To describe male first-line managers' experiences of their work situation in elderly care. BACKGROUND: First-line managers' work is challenging. However, less attention has been paid to male managers' work situation in health care. Knowledge is needed to empower male managers. METHOD: Fourteen male first-line managers were interviewed. The interview text was subjected to qualitative content analysis. RESULT: Work situations were described as complex and challenging; challenges were the driving force. They talked about 'Being on one's own but not feeling left alone', 'Having freedom within set boundaries', 'Feeling a sense of satisfaction and stimulation', 'Feeling a sense of frustration' and 'Having a feeling of dejection and resignation'. CONCLUSION: Although the male managers report deficiencies in the support structure, they largely experience their work as a positive challenge. IMPLICATIONS FOR NURSING MANAGEMENT: To meet increasing challenges, male first-line managers need better access to supportive structural conditions. Better access to resources is needed in particular, allowing managers to be more visible for staff and to work with development and quality issues instead of administrative tasks. Regarding organisational changes and the scrutiny of management and the media, they lack and thus need support and information from superiors.

First-line managers' descriptions and reflections regarding their staff's access to empowering structures.

AIM: To elucidate first-line managers' descriptions and reflections regarding their staff's access to empowering structures using Kanter's theory of structural empowerment. BACKGROUND: Good structural conditions within workplaces are essential to employees' wellbeing, and their ability to access empowerment structures is largely dependent on the management. METHOD: Twenty-eight first-line managers in elderly care were interviewed. Deductive qualitative content analysis was used to analyse data. RESULTS: Managers perceived that staff had varying degrees of access to the empowering structures described in Kanter's theory - and that they possessed formal power in their roles as contact persons and representatives. The descriptions mostly started from the managers' own actions, although some started from the needs of staff members. CONCLUSION: All managers described their staff's access to the empowering structures in Kanter's theory as important, yet it seemed as though this was not always reflected on and discussed as a strategic issue. IMPLICATIONS FOR NURSING MANAGEMENT: Managers could make use of performance and appraisal dialogues to keep up to date on staff's access to empowering structures. Recurrent discussions in the management group based on such current information could promote staff's access to power through empowering structures and make job definitions a strategic issue in the organisation.