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.

The knowledge desired by emergency medical service managers of their ambulance clinicians - A modified Delphi study.

AIM: The aim of the study was to identify the types of knowledge that Swedish Emergency Medical Service (EMS) managers considered desirable in their Ambulance Clinicians. BACKGROUND: Emergency medical service managers are responsible for organisational tasking and in this are dependent on the knowledge possessed by their ambulance clinicians. It would therefore be of value to explore EMS managers' approach to this knowledge. DESIGN: A modified Delphi method in three rounds. METHODS: In total thirty-six EMS managers participated, and twenty-four finished all three rounds. They were encouraged to rate each sub-category, and the ten with the highest mean were interdependently ranked in the final round. RESULTS: Five categories and twenty-six sub-categories emerged in the first round, covering knowledge related to; contextual aspects, medical and holistic assessments, formal education and organisational issues. Eventually, the sub-category 'Knowledge to assess the patient's situation from a holistic perspective' was the highest ranked, followed by 'Medical knowledge to assess and care for different diseases' and 'Knowledge to be able to care for critically ill patients'. CONCLUSIONS: Taken together the knowledge areas address essentially medical care, contextual aspects and nursing. The boundaries between these can sometimes be seen as elusive, calling for ambulance clinicians to balance these areas of knowledge.

Acquisition of extended spectrum ß-lactamases during travel abroad-A qualitative study among Swedish travellers examining their knowledge, risk assessment, and behaviour.

BACKGROUND: Travel to foreign countries involves the risk of becoming a carrier of antibiotic-resistant bacteria, especially when the destination is a country with a high prevalence of this type of bacteria. AIM AND METHODS: The aim of this study was to learn about the knowledge of antibiotic resistance, and the behaviour and risk-taking among travellers, who had become carriers of extended spectrum beta-lactamases (ESBL)-producing bacteria during travel to a high-prevalence country. A modified version of grounded theory was used to analyse 15 open interviews. RESULTS: The analysis resulted in a core category: A need for knowledge to avoid risk-taking. Before the journey, the participants did not perceive there to be any risk of becoming a carrier of antibiotic- resistant bacteria. The low level of knowledge of antibiotic-resistant bacteria and transmission routes influenced their behaviour and risk-taking during their journey, resulting in them exposing themselves to risk situations. After their trip, the majority did not believe that their personal risk behaviour could have caused them to become carriers of ESBL. CONCLUSION: The participants' lack of knowledge of antibiotic-resistant bacteria resulted in unconscious risk-taking during their journey, which may have resulted in becoming carriers of ESBL-producing bacteria.

Encumbered by vulnerability and temporality - the meanings of trigger situations when learning to live with diabetes.

AIMS AND OBJECTIVES: The aim of the study was to illuminate the meanings of trigger situations experienced in everyday life when learning to live with diabetes. BACKGROUND: Adults become active learners when faced with situations they do not know how to manage, triggering a need to understand something in a different way than before. Knowing more about experiential learning for persons living with diabetes is important for understanding how learning can be supported by health care. DESIGN: A life-world approach with a phenomenological hermeneutical method, inspired by the philosophy of Paul Ricoeur. METHODS: This method was used for interpreting transcriptions of interviews and consists of three stages: naïve understanding, structural analysis and a comprehensive understanding. Participants (n = 13), with either type I or type II diabetes, were interviewed on three different occasions over a three-year period after being diagnosed with diabetes. RESULTS: When learning to live with diabetes, the meanings of trigger situations were described as 'the unpredictable body heightens insecurity with awareness of one's own dependability', 'losing control in unsustainable situations' and 'encumbered by vulnerability and temporality in earlier familiar situations'. CONCLUSION: The meanings of trigger situations were to lose the smooth, unreflected way of managing an everyday life situation, interlaced with feelings of lost control of how to live with new insights of being vulnerable. Trigger situations meant an opportunity for learning, as well as being demanding, unplanned and with limited freedom of choice. Trigger situations presented life and body as unpredictable. RELEVANCE TO CLINICAL PRACTICE: If healthcare professionals can identify the worries and questions raised in trigger situations, knowledge gaps can be identified and reflected on to stimulate learning.

'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.

The relationship with the ambulance clinicians as experienced by significant others.

BACKGROUND: Interpersonal relationships between clinicians and patients are important aspects of the ambulance care, requiring a balance between objectified acute medical treatment and a holistic care. Being a significant other (SO) in the ambulance care setting is described as being caught between hope and dread. Little research has focused on SOs' experiences of the relationship with the ambulance clinicians. AIM: To elucidate meanings of the relationship with the clinicians in the ambulance care setting as experienced by the patients' SOs. DESIGN: Qualitative lifeworld design. METHODS: Data was collected using open-ended interviews with nine SOs. The verbatim transcribed interviews were analysed with a phenomenological hermeneutic method. FINDINGS: The structural analysis resulted in one main theme: 'Being lonely together'. The main theme comprises three themes: 'Being in a shared struggle', 'To hand over the affected person in trust' and 'Being the second person in focus' and six subthemes. The main theme is for the SOs to share the struggles of the affected person with the ambulance clinicians and to be comforted while handing over the responsibility for the affected person. Hence the SO is excluded and lonely and on his/her own, while not the primary focus of the ambulance clinicians. CONCLUSIONS: The relationship with the ambulance clinicians from the perspective of the SOs can be understood as complex, involving both being lonely and together at the same time. The findings support a holistic approach towards the ambulance care involving SOs. RELEVANCE FOR CLINICAL PRACTICE: This study outlines the importance of an emergency ambulance care involving SOs as affected persons and supports a balance between emergency medical treatment to the patient and a holistic care, involving the SOs' suffering.

Ambulance clinicians' experiences of relationships with patients and significant others.

BACKGROUND: Ambulance clinicians (ACs) have to provide advanced care and treatment to patients in a challenging and emotionally demanding environment, therefore they establish interpersonal relationships embracing both patients and significant others. Relationships in emergency care were earlier found to be short-lived and lacking a holistic understanding of the patient. In their relationship with the ambulance clinicians, it is for patients to surrender and become dependent, which may be interpreted as both a negative and a positive experience. AIM: The aim of this study was to elucidate ambulance clinicians' experiences of relationships with patients and significant others. METHODS: Data were collected from four focus group conversations, with a total of 18 participating ambulance clinicians. An inductive qualitative content analysis method was chosen. FINDINGS: The analysis resulted in one main category: 'To be personal in a professional role' and three generic categories: 'To be there for the affected person', 'To be personally involved' and 'To have a professional mission'. There were subsequently nine sub-categories. The main category was described as intertwining the experience of being both personal and professional. The ambulance clinicians adapt to a situation while having the affected person in focus. They involve themselves as persons but at the same time use the power of their professional role. CONCLUSION: The relationship with patients and significant others from the ambulance clinicians' perspective can be understood as embracing both personal and professional aspects. RELEVANCE TO CLINICAL PRACTICE: This study provides an understanding of the ambulance clinicians' professional role as embracing a personal perspective, which is important when developing an emergency ambulance service focusing on care that involves more than just emergency medical treatment.

Understanding the role of an educational model in developing knowledge of caring for older persons with dementia.

BACKGROUND: Statistics show that the number of older people in need of care is increasing worldwide, especially those with dementia. This implies demands on knowledge and competence among health care staff to care for them. In Sweden, Silviahemmet offers dementia care units the opportunity to become certified according to a special certification educational model. Silviahemmet provides educational programs for staff in dementia care and day care for person with dementia. All staff undergoes a systematic training course in dementia care. The aim of the study was to gain an understanding of how an educational model developed the perceived knowledge of staff caring for older persons with dementia in a nursing home. METHOD: A phenomenographical approach was used and qualitative interviews were carried out with 13 staff members in a nursing home. FINDINGS: The main results show that staff perceives the importance of knowledge, working together and creating a sense of fellowship. The care of persons with dementia requires a special approach and adherence. Participating in the educational program made the staff realize and acknowledge their tacit knowledge and the importance of reflection-in-action together in the team. CONCLUSION: The results indicate the need for a common theoretical knowledge base and value system to achieve coherence in daily work.

Staff experiences of caring for patients with extended-spectrum ß-lactamase-producing bacteria: A qualitative study.

BACKGROUND: Patients who become carriers of antibiotic-resistant bacteria are sometimes stigmatized by health professionals. Staff members' fears of becoming infected could affect their willingness to care for these patients. METHODS: The purpose of this study was to increase the knowledge of what it means for staff in acute care settings and nursing homes to care for patients with extended-spectrum ß-lactamase (ESBL)-producing bacteria. Assistant nurses, registered nurses, and physicians from acute care settings and nursing homes were interviewed. A modified version of Grounded Theory was used for the analysis. RESULTS: The analysis resulted in the core category "to operate as an expert in a chaotic environment" in acute care settings. Despite a lack of resources, hospital staff try to provide the best possible care for patients with ESBL. The analysis of the interviews in the nursing homes resulted in the core category "the employee who, despite uncertainty, provides good care." Despite some fear, and a lack of knowledge, the study participants tried to provide the residents with good care. CONCLUSION: Staff in acute care settings and nursing homes must have adequate knowledge and reasonable working conditions to be able to provide high-quality care for patients and residents who are ESBL carriers.

Is the competence of Swedish Registered Nurses working in municipal care of older people merely a question of age and postgraduate education?

OBJECTIVES: Previous studies suggest that not only education but also personal aspects such as experience of working as a registered nurse (RN) and age can influence competence. The objective was to explore the educational and self-rated competence of RNs and their duties within the care of older people. METHODS: A cross-sectional descriptive design was used. All RNs in two counties in Sweden were asked to complete a written questionnaire: a study specific questionnaire with educational and work related questions using the Nurse Competence Scale. The response rate was 61% (n 344). RESULTS: Higher self-rated satisfaction with own professional competence was related to older age, more years after nursing education and possessing at least one postgraduate education in specialist nursing. Educational needs were related to younger age and fewer years since nursing graduation. Education within elder care, including education about drugs was rated the most urgently needed area of education. The most frequently reported tasks were found in the domain helping role, whereas ensuring quality was less present in their daily work. CONCLUSIONS: Educational level, age and years of experience had an impact on RNs' self-perceived competence, which is in accordance with previous descriptions of the concept competence. It seems imperative that RNs working in care of the old and with the demands placed on them are given the opportunity to take a postgraduate specialist education in order to gain a competence level in their desired area of work. It is also important that RNs working in care of the old get tailored education in line with the requirements the organisation places on them.

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.

Living with diabetes - development of learning patterns over a 3-year period.

BACKGROUND: Learning involves acquiring new knowledge and skills, and changing our ways of thinking, acting, and feeling. Learning in relation to living with diabetes is a lifelong process where there is limited knowledge of how it is experienced and established over time. It was considered important to explore how learning was developed over time for persons living with diabetes. AIM: The aim of the study was to identify patterns in learning when living with diabetes, from recently being diagnosed, and over a 3-year period. MATERIALS AND METHODS: A longitudinal qualitative descriptive design was used. Thirteen participants, with both type I and type II diabetes, were interviewed at three different occasions during a 3-year period. Qualitative content analysis was used in different steps in order to distinguish patterns. FINDINGS: Five main patterns of learning were identified. Two of the patterns (I and II) were characterized by gradually becoming comfortable living with diabetes, whereas for one pattern (IV) living with diabetes became gradually more difficult. For pattern V living with diabetes was making only a limited impact on life, whereas for Pattern III there was a constant management of obstacles related to illness. The different patterns in the present study showed common and different ways of learning and using different learning strategies at different timespans. CONCLUSION: The present study showed that duration of illness is not of importance for how far a person has come in his own learning process. A person-centered care is needed to meet the different and changing needs of persons living with diabetes in relation to learning to live with a lifelong illness.

Attitudes towards caring for older people in Scotland, Sweden and the United States.

AIM: To explore the attitudes of nurses and nursing students in Scotland, Sweden and the US towards working with older people. METHOD: This quantitative study used the 20-item Multifactorial Attitudes Questionnaire (MAQ) to elicit attitudes on ageism, resources, working environment, education and professional esteem. Researchers from each country distributed the questionnaires to nursing students and nurses, giving a convenience sample of 1,587 respondents. Data were entered on the Statistical Package for Social Sciences version 18 and merged into one large dataset. RESULTS: Scottish participants had the highest (positive) and Swedish participants the lowest mean MAQ score. The Kruskal-Wallis test showed significant differences in mean scores across the countries in 18 of the 20 statements, even when controlling for age and experience. Most participants gave positive responses, but agreed that negative attitudes towards working with older people pervade among peers due to working conditions, poor career prospects and a perceived lack of professional esteem. CONCLUSION: Inspirational educators, excellent clinical placements and increasing the professional esteem of those working with older people are required to promote the specialty as an attractive career option.

To surrender in dependence of another: the relationship with the ambulance clinicians as experienced by patients.

Historically, the ambulance care has focused on acute transports and medical treatment, although ambulance care has also been reported as complex, encompassing more than just medical treatment and transports. Previous studies, on ambulance clinicians, have pointed out the importance of interpersonal caring activities complementary to the medical treatment. Those activities can be understood as taking part in the relationship between patients and ambulance clinicians, earlier described as essential and a core component of care. The aim of this study was to elucidate the meaning of the relationship with the ambulance clinicians as experienced by patients. Twenty ambulance patients were interviewed in the study. The interviews were transcribed verbatim and analysed with a phenomenological hermeneutical method to grasp meanings in the patients' experiences. The regional ethical committee approved the study. In the result emerged one main theme: To surrender in dependence of another. The main theme includes four themes: Being in the hands of another, Being in a caring temporary presence, Being important while involved and Being powerless while insignificant, and the themes comprise eleven subthemes. The main theme meant to have no other option than to surrender and to put their life into the hand of another. This surrender also meant to adapt to the clinicians' views even if not shared. This is experienced as excessive care. Summarised, the patients' experiences were both positive and negative and the findings provide a complex understanding of the relationship between the patient and the ambulance clinicians. Overall, the relationship embraces the whole person without reducing the patient to be a recipient of an objectified ambulance care.

Living with Uncertainty: Older Persons' Lived Experience of Making Independent Decisions over Time.

The aim of the study was to illuminate the meaning of older persons' independent decision making concerning their daily care. Autonomy when in care is highly valued in the western world. However, research shows that autonomy can give rise to problematic issues. The complexity of independence and dependence for older people when living at home with help has also been highlighted. In Sweden, older people are increasingly expected to live at home with help from municipal home care services, and study into this aspect of care is limited. This study is a part of an ongoing project and has a qualitative life world perspective. Audiotaped narrative interviews were conducted and analysed using a phenomenological hermeneutic method. Findings revealed a main theme: "living with uncertainty as to how to relate one's own independence and dependence with regard to oneself, and others." This involves a constant process of relating to one's independence controlled by others or oneself, and adjusting one's independence and dependence with regard to oneself and others. The conclusion is that professional carers need to acknowledge the changing vulnerability of dependent older persons over time. The implication is a relational approach to autonomy beyond the traditional individualistic approach.

Carers' ambivalence in conflict situations with older persons.

The aim of this study was to illuminate the meaning of professional carers' experiences in caring situations when a conflict of interest arises with the older person receiving care. The findings reveal the complexity of the carers' ambivalence when facing a conflict of interest, weighing up between the older persons' right to self-determination and external demands. The carers are alone in their ambivalence, and the conclusion is that they need help and support to be more present in the encounter. The implication for this study is to focus on care as a person-centered practice and to focus on people as interdependent on support carers to maintain older people's right to self-determination in the relationship.

Older people's dependence on caregivers' help in their own homes and their lived experiences of their opportunity to make independent decisions.

AIM: The aim of this study was to illuminate the meaning of older people's dependence on caregivers' help, and of their opportunity to make independent decisions. BACKGROUND: Throughout the world, the older population is growing, and in Sweden, the system of care for older people is currently undergoing change. Older people in the need of care are expected to live at home for as long as possible. DESIGN: A qualitative and life world approach was used. METHODS: Audio-taped interviews were conducted with twelve older persons living at home, dependent on daily municipal home help service. A phenomenological hermeneutic method was utilised to disclose the meanings of lived experiences. FINDING: The findings revealed three themes: being facilitated to make one's own decisions, being hindered from making one's own decisions, struggling for vs. resigning oneself to losing the opportunity to make one's own decisions. The comprehensive understanding revealed that as older people become more dependent on caregivers' help, their opportunity to self-determine is challenged and this is stressful for them. CONCLUSION: The older persons assess their opportunity to self-determine differently, depending on who they are as a person. The caregivers need an awareness of this, and further research is needed to gain knowledge and understanding of how caregivers can improve the way they support and enhance older people's opportunity to decide for themselves. IMPLICATIONS FOR PRACTICE: The findings revealed older persons need to exercise more self-determination and caregivers' need for knowledge to enable this. Further, it indicates a move towards a person-centred approach to focus on persons as individuals and see them as interdependent. The findings contribute to improvements in similar contexts worldwide.

Specialist prescribing of psychotropic drugs to older persons in Sweden--a register-based study of 188,024 older persons.

BACKGROUND: The situation for older persons with mental disorders other than dementia disorders has scarcely been studied. The older population is increasing worldwide and along with this increase the prevalence of mental disorders will also rise. The treatment of older persons with mental disorders entails complex challenges, with drugs constituting the major medical treatment. Knowledge of geriatric psychiatry is essential for providing older persons with appropriate treatment and care. This study aimed to evaluate the prescription of drugs for mental disorders to older persons (≥ 65) in Sweden, focused on the medical specialties of the prescribing physicians. METHODS: Data concerning drug treatment for older persons from 2006 to 2008 was gathered from the Swedish Prescribed Drug Register. Mental disorders, defined as affective, psychotic and anxiety disorders (ICD-10 F20-42) were evaluated in order to identify associated drugs. Included was a total of 188,024 older individuals, who collectively filled 2,013,079 prescriptions for the treatment of mental disorders. Descriptive analyses were performed, including frequency distribution and 95% CI. The competence of the prescribers was analyzed by subdividing them into five groups: geriatricians, psychiatrists, general practitioners (GPs), other specialists, and physicians without specialist education. RESULTS: GPs represented the main prescribers, whereas geriatricians and psychiatrists rarely prescribed drugs to older persons. Benzodiazepines and tricyclic antidepressants were the most commonly prescribed drugs. Women were prescribed drugs from geriatricians and psychiatrists to a greater extent than men. CONCLUSIONS: This study examined the prescription of psychotropic drugs to older persons. Physicians specialized in older persons' disorders and mental health were rarely the prescribers of these drugs. Contrary to clinical guidelines, benzodiazepines and tricyclic antidepressants were commonly prescribed to older persons, emphasizing the need for continuous examination of pharmaceutical treatment for older persons. The results indicate a future need of more specialists in geriatrics and psychiatry.

Struggling for existence-Life situation experiences of older persons with mental disorders.

Older persons with mental disorders represent a vulnerable group of people with extensive and complex needs. The older population is rapidly increasing worldwide and, as a result of deinstitutionalization in mental health care, older persons are remaining at home to a greater extent. Although they constitute a large proportion of the population, older persons with mental disorders have been neglected in research as well as in care organizations. As there is little previous knowledge concerning older persons' experiences of their own situations, this study aimed to illuminate the meaning of the life situation as experienced by older persons with mental disorders (excluding dementia disorders). Interviews were conducted with seven older persons and the text was analyzed using a phenomenological hermeneutical research method, inspired by the philosophy of Paul Ricoeur. "Struggling for existence" emerged as a main theme in the older persons' narratives, understood as a loss of dignity of identity and involving being troubled and powerless as well as yearning for respect. The older persons fought to master their existence and to be seen for who they are. The study highlights the importance for caregivers, both formal and informal, to avoid focusing on the diagnoses and rather acknowledge the older persons and their lifeworld, be present in the relation and help them rebuild their dignity of identity. This study brings a new understanding about older persons with mental disorders that may help reduce stigma and contribute to planning future mental health care.