General practitioners' knowledge of leg ulcer treatment in primary healthcare: an interview study.

AIM: To describe general practitioners' (GPs') knowledge and the development of their knowledge regarding leg ulcer treatment when treating patients with leg ulceration at primary healthcare centers. BACKGROUND: Earlier research regarding GPs' knowledge of leg ulcer treatment in a primary healthcare context has focused primarily on the assessment of wounds and knowledge of wound care products. Less is known about GPs' understandings of their own knowledge and knowledge development regarding leg ulceration in the everyday clinical context. This study, therefore, sets out to highlight these aspects from the GPs' perspective. METHODS: Semi-structured interviews were conducted with 16 individual GPs working at both private and county council run healthcare centers. The data were analyzed inductively using a thematic analysis. RESULTS: Four themes were identified. 'Education and training' describe the GPs' views regarding their knowledge and knowledge development in relation to leg ulcer treatment. 'Experience' refers to GPs' thoughts about the importance of clinical experience when treating leg ulcers. 'Prioritization' describes the issues GPs raised around managing the different knowledge areas in their clinical work. 'Time constraints' explore the relationship between GPs' sense of time pressure and their opportunities to participate in professional development courses. CONCLUSIONS: The study shows that the GPs working in primary healthcare are aware of the need for ongoing competence development concerning leg ulceration. They describe their current knowledge of leg ulcer treatment as insufficient and point to the lack of relevant courses that are adapted for their level of knowledge and the limited opportunities for clinical training.

Stepping out of the shadows of Alzheimer's disease: a phenomenological hermeneutic study of older people with Alzheimer's disease caring for a therapy dog.

PURPOSE: Living with Alzheimer's disease (AD) can involve a person being unable to recall and convey information in daily life. There are several ways to provide person-centred care to older people with AD, e.g. by empowering them in a situation. The use of animal-assisted therapy (AAT) with a therapy dog in the care of people with dementia is increasing, with the presence of a therapy dog being described as improving, among other things, the well-being and socialization of the person. The aim of this study was to illuminate meanings of care for people with AD in their encounters with a therapy dog. METHOD: The study used video-recorded observations of the person with AD and the dog. Data were transcribed and analysed using a phenomenological hermeneutic method. RESULTS: The main theme was "Using one's own resources and abilities as a human being", which meant being the person one can be and distancing oneself from the symptoms of AD during the time with the dog. CONCLUSIONS: The feelings evoked in the people with AD included empathy and altruism, which allowed for a sense of joy and tenderness, which may induce a sense of self-worth, of being needed, and of being meaningful.

Nutritional assessment and post-procedural complications in older stroke patients after insertion of percutaneous endoscopic gastrostomy - a retrospective study.

BACKGROUND: Oropharyngeal dysphagia is one of the major complications of stroke and a risk factor for malnutrition and prolonged in-hospital stay. OBJECTIVE: The overall aim was to describe to what extent nutritional assessments (i.e. BMI kg/m(2), eating problem, and weight loss) were performed and documented in the records of older stroke patients treated with enteral nutrition by percutaneous endoscopic gastrostomy (PEG). A secondary aim was to identify documented post-procedural complications after PEG insertion during hospital stay. DESIGN: The study is retrospective. Data were collected from records of 161 stroke patients ≥65 years, who received PEG, admitted to three stroke units during a 4-year period. RESULTS: Mean age of the patients was 82.2 (±7) years, and 86% of the patients were ≥75 years old. On admission, body weight was documented in 50% of the patients and at discharge in 38% of the patients. BMI data were not documented at all at discharge in one of the units. Almost 80% of the patients fulfilled the European Network criteria for multimorbidity. Morbidity and multimorbidity correlated to the length of stay (p<0.0005). Complications were reported in 111 (69%) of the patient records. In 53 patients (33%) more than one complication was reported. A total of 116 pressure ulcers were reported and 30 patients had more than one pressure ulcer. The number of complications was related to weight loss (p=0.046) and BMI change (p=0.018). CONCLUSIONS: Essential information of the patient's nutritional status was poorly recorded which could affect the patient's nutritional treatment during the hospital stay. This study indicates that implementation of guidelines in patients with stroke is needed. The high number of pressure ulcers was an unexpected finding.

'Bringing respite in the burden of illness' - dog handlers' experience of visiting older persons with dementia together with a therapy dog.

AIMS AND OBJECTIVES: To illuminate meanings of the lived experiences of dog handlers' when visiting older persons with dementia with their therapy dog. BACKGROUND: Studies indicate that care of persons with dementia should focus on a person-centred approach with the person's interests in the centre. Animal-assisted therapy using a therapy dog in the care of persons with dementia has been shown to increase well-being and decrease problematic behaviours associated with the illness. DESIGN: A qualitative lifeworld approach was adopted for this study. METHODS: Data were collected from open-ended interviews with nine dog handlers, and the analysis conducted using the phenomenological hermeneutical method. RESULTS: The structural analysis resulted in one theme, 'Respite from the burden of illness for persons with dementia'. CONCLUSIONS: Visiting a person with dementia can be seen as an act of caring, providing temporary respite from their illness, and creating a special relationship between handler and patient. A therapy dog visit can represent a moment of communion between the handler and the person with dementia. IMPLICATION FOR CLINICAL PRACTICE: Dog handlers use their skills and knowledge to promote a situation that reduces symptoms of illness and encourages healthier behaviour. The results of this study may be of interest to researchers, clinical practitioners, caregivers and dog handlers who care for persons with dementia using therapy dog teams on prescription as an alternative method to minimise behavioural and psychological symptoms of dementia.

Can therapy dogs evoke awareness of one's past and present life in persons with Alzheimer's disease?

BACKGROUND: Persons with Alzheimer's disease (AD) sometimes express themselves through behaviours that are difficult to manage for themselves and their caregivers, and to minimise these symptoms alternative methods are recommended. For some time now, animals have been introduced in different ways into the environment of persons with dementia. Animal-Assisted Therapy (AAT) includes prescribed therapy dogs visiting the person with dementia for a specific purpose. AIM: This study aims to illuminate the meaning of the lived experience of encounters with a therapy dog for persons with Alzheimer's disease. METHOD: Video recorded sessions were conducted for each visit of the dog and its handler to a person with AD (10 times/person). The observations have a life-world approach and were transcribed and analysed using a phenomenological hermeneutical approach. RESULTS: The result shows a main theme 'Being aware of one's past and present existence', meaning to connect with one's senses and memories and to reflect upon these with the dog. The time spent with the dog shows the person recounting memories and feelings, and enables an opportunity to reach the person on a cognitive level. CONCLUSIONS: The present study may contribute to health care research and provide knowledge about the use of trained therapy dogs in the care of older persons with AD in a way that might increase quality of life and well-being in persons with dementia. IMPLICATIONS FOR PRACTICE: The study might be useful for caregivers and dog handlers in the care of older persons with dementia.

Mental health-promoting dialogues from the perspective of community-dwelling seniors with multimorbidity.

Mental health promotion needs to be studied more deeply within the context of primary care, because persons with multiple chronic conditions are at risk of developing poor mental health. In order to make progress in the understanding of mental health promotion, the aim of this study was to describe the experiences of health-promoting dialogues from the perspective of community-dwelling seniors with multimorbidity - what these seniors believe is important for achieving a dialogue that may promote their mental health. Seven interviews with six women and one man, aged 83-96 years, were analyzed using qualitative content analysis. The results were summarized into nine subcategories and three categories. The underlying meaning of the text was formulated into an overarching theme that embraced every category, "perceived and well-managed as a unique individual". These seniors with multimorbidity missed someone to talk to about their mental health, and needed partners that were accessible for health dialogues that could promote mental health. The participants missed friends and relatives to talk to and they (crucially) lacked health care or social service providers for health-promoting dialogues that may promote mental health. An optimal level of care can be achieved through involvement, continuity, and by providing a health-promoting dialogue based on seniors' needs and wishes, with the remembrance that general health promotion also may promote mental health. Implications for clinical practice and further research are discussed.

District nurses' knowledge development in wound management: ongoing learning without organizational support.

AIM: The aim of this study was to describe district nurses' (DNs') experiences of their knowledge development in wound management when treating patients with different types of wounds at healthcare centers. BACKGROUND: In primary healthcare, DNs are mainly responsible for wound management. Previous research has focused on DNs' level of expertise regarding wound management, mostly based on quantitative studies. An unanswered question concerns DNs' knowledge development in wound management. The present study therefore intends to broaden understanding and to provide deeper knowledge in regard to the DNs' experiences of their knowledge development when treating patients with wounds. METHODS: A qualitative descriptive design was used. Subjects were a purposeful sample of 16 DNs from eight healthcare centers in a metropolitan area in Stockholm, Sweden. The study was conducted with qualitative interviews and qualitative content analysis was used to analyze the data. RESULTS: The content analysis resulted in three categories and 11 sub-categories. The first category, 'ongoing learning by experience,' was based on experiences of learning alongside clinical practice. The second category 'searching for information,' consisted of various channels for obtaining information. The third category, 'lacking organizational support,' consisted of experiences related to the DNs' work organization, which hindered their development in wound care knowledge. CONCLUSIONS: The DNs experienced that they were in a constant state of learning and obtained their wound care knowledge to a great extent through practical work, from their colleagues as well as from various companies. A lack of organizational structures and support from staff management made it difficult for DNs to develop their knowledge and skills in wound management, which can lead to inadequate wound management.

Inflammatory bowel disease professionals' attitudes to and experiences of complementary and alternative medicine.

BACKGROUND: Complementary and alternative medicine (CAM) use in patients with IBD is on the increase. Patients report they use CAM when their condition is unresponsive to conventional medication or when they suffer from side-effects, negative stress and disease-related concerns. CAM use may improve patients' well-being but it can also lead to side-effects and interactions with conventional medications. Research on attitudes to and experiences of CAM among healthcare professionals working with IBD patients is not well studied. Studies in this area could lead to enhanced awareness of and improved communication about CAM between care staff and IBD patients. The aim of this study was to explore IBD professionals' attitudes to and experience of CAM. METHODS: Sixteen physicians and nurses, 26-70 years old, who had worked with IBD patients for 1-42 years, were recruited. Semi-structured qualitative interviews were conducted. Qualitative content analysis was performed. RESULTS: Participants stated patients used CAM to improve their well-being generally and there conditions specifically. Participants had a positive attitude towards CAM and respected their patients' decision to use it, but reported a lack of CAM knowledge. They required education about CAM to be able to meet patients' needs and provide adequate information. The result of this study indicates that there is a need for CAM education to be implemented in nursing and medical school. CONCLUSIONS: All participants had experience of IBD patients who had used CAM in an attempt to achieve improvement and well-being. Attitudes to CAM were mainly positive, although a problematic aspect was lack of knowledge and evidence in relation to CAM. Implementing CAM education in nursing and medical school will allow healthcare professionals to gain an understanding of therapies widely used by patients with IBD. In clinical practice, using a standard questionnaire regarding CAM use allow healthcare professionals to better understand their patients' wishes and current CAM use.

How community-dwelling seniors with multimorbidity conceive the concept of mental health and factors that may influence it: a phenomenographic study.

Multimorbidity, that is, the coexistence of chronic diseases, is associated with mental health issues among elderly people. In Sweden, seniors with multimorbidity often live at home and receive care from nursing aides and district nurses. The aim of this study was to describe the variation in how community-dwelling seniors with multimorbidity perceive the concept of mental health and what may influence it. Thirteen semi-structured interviews were analysed using a phenomenographic approach. Six qualitatively different ways of understanding the concept of mental health and factors that may influence it, reflecting key variations of meaning, were identified. The discerned categories were: mental health is dependent on desirable feelings and social contacts, mental health is dependent on undesirable feelings and social isolation, mental health is dependent on power of the mind and ability to control thoughts, mental health is dependent on powerlessness of the mind and inability to control thoughts, mental health is dependent on active behaviour and a healthy lifestyle, and mental health is dependent on passive behaviour and physical inactivity. According to the respondents' view, the concept of mental health can be defined as how an individual feels, thinks, and acts and also includes a positive as well as a negative aspect. Social contacts, physical activity, and optimism may improve mental health while social isolation, ageing, and chronic pain may worsen it. Findings highlight the importance of individually definitions of mental health and that community-dwelling seniors with multimorbidity may describe how multiple chronic conditions can affect their life situation. It is essential to organize the health care system to provide individual health promotion dialogues, and future research should address the prerequisites for conducting mental health promotion dialogues.

Living in a paradox--women's experiences of body and life-world after meningioma surgery.

AIMS: The aims of the study were to describe how persons who have undergone benign meningioma surgery experience their body and life-world and to illuminate the meaning of the illness, operation and recovery. BACKGROUND: Meningioma, which is often benign, is the most commonly diagnosed brain tumour. Studies have shown that persons with meningioma tend to be more psychologically affected than persons with other brain tumours. To our knowledge, no previous studies have focused on the life-world or body experience of these persons. METHOD: Narrative interviews with seven women conducted over a 6-month period (2008-2009) were analyzed using a phenomenological hermeneutical method. Findings. Four themes were identified: In between double threats: the tumour and operation: the participants seemed to perceive a paradox in the sense that the tumour was both benign and threatening and the surgery both curing and risky; the wound as an open gate: the wound is visibly healed, but perceived as unhealed; the suffering body overflows life: the participants were prevented from regaining their body, feeling fragile and oversensitive to impressions; and the need to be embraced by attention: taking the participants' needs seriously facilitated understanding of the diagnosis. CONCLUSION: The participants in this study described emotional distress when recovering from meningioma surgery. It is essential for nurses to be aware of the various meanings people ascribe to events that disrupt their lives and the transition process in connection with meningioma treatment.

Wound care by district nurses at primary healthcare centres: a challenging task without authority or resources.

There is a lack of studies that describes how district nurses experience the care they provide in connection with wound care. The aim of this study was therefore to describe district nurses experiences of their nursing actions when treating patients with different kinds of wounds at primary healthcare centres and in the home care in order to increase understanding of this kind of care. A qualitative, descriptive study was conducted, with interviews of eight district nurses. Data were analysed using qualitative content analysis. Three themes and nine sub-themes were identified. The first theme included two sub-themes which revealed that in performing wound care district nurses feel responsible for administering wound care, and they feel confident in making independent assessments. The second theme included three sub-themes which revealed that district nurses endeavour to assess all aspects of their patient's situation and to maintain continuity in both their contact with the patient and the treatment. A treatment plan for wound care and regular reports were identified as being important in collaboration with other healthcare professionals. District nurses wanted their own procedure for referral to facilitate the patient's direct contact with a dermatologist. The third theme included four sub-themes which revealed difficulties associated with ambiguous organisation. Lack of time led to the dressing of wounds being delegated to nursing assistants. Limited access to treatment rooms and equipment made wound care difficult and inefficient. Wound care in the home care was regarded as challenging due to the lack of equipment, and poor lighting, ergonomics and hygiene. The results of this study thus identified the aspirations of district nurses to provide expert wound care while working independently. However, these aspirations were aggravated by organisational shortcomings, such as a lack of authority and the resources required to carry out their nursing actions optimally.

Wound care in primary health care: district nurses' needs for co-operation and well-functioning organization.

Most patients with leg- and foot ulcers are managed within non-institutional care. The aim of this study was to investigate the district nurses' wound management, including wound appearance, assignment of responsibility, guidelines for wound treatment and co-operation with other professional groups. The study has a descriptive quantitative approach. Data was collected using a wound registration form and a questionnaire. The selection of participants was made by random sampling. District nurses (n = 26) in five health-care centers situated in central Stockholm and two of its suburbs, participated in the study. The results show that the wound appearance is dominated by traumatic wounds. Approximately 40% of the wounds were not medically diagnosed. The area of responsibility of different professional groups was not defined and guidelines for wound treatment were mostly lacking. The decision about wound management was generally made by the district nurse. Co-operation with the general practitioner was lacking and when a consultation with dermatologist was required, the routines concerning referral were undefined. Co-operation with the assistant nurses consisted of redressing the wounds in home care. Interprofessional co-operation was regarded as important for wound healing. The paper provides insights into the district nurses' wound management and co-operation in wound care.

Older patients' experience of dressing changes on venous leg ulcers: more than just a docile patient.

AIM AND OBJECTIVE: The aim of this paper was to describe the lived experiences of older patients with venous leg ulcers, during dressing changes as out patients with a focus of their concerns about care interventions. Research on wound care management has focused on treatment of venous leg ulcer, wound assessments and the choice of dressing material. Few studies have focused on the patients' experience of dressing changes. DESIGN: Fifteen older people with verified venous leg ulcers were recruited in a metropolitan area of Sweden. Data were collected with research interviews in the form of dialogue. METHOD: Data were analysed with an interpretative phenomenological method developed by Benner. RESULTS: Twelve women and three men participated. The themes were: 'being cared for with a skillful touch', 'feelings of belonging, continuity and affinity', and 'being suppressed into a state where one loses control, leading to feelings of discomfort'. The participants' experiences varied. Some were satisfied and felt that there was a mutual understanding between caregivers and patients, while others were dissatisfied and felt objectified. Understanding the patients as human beings and considering illness as lived experience helped the care providers to perform skillful wound care, in an atmosphere of mutual understanding. CONCLUSION: The patients suffering from venous leg ulcers wanted to feel worthy of wound treatment and to meet skillful, confident and gentle nurses in a sharing atmosphere. Nurses must be perceptive to the individual's bodily experience of the leg ulcer. RELEVANCE TO CLINICAL PRACTICE: Wound care requires a multidimensional clinical approach that involves not only medical and technical care strategies of dressings and bandages, but also aspects that concern the situated-based illness experience that persons suffering from leg ulcers may face.