Pain prevalence among residents living in nursing homes and its association with quality of life and well-being.

BACKGROUND: Pain is common and often more complex to assess among nursing homes residents with cognitive impairments. Thus, more research is needed of different pain assessment methods in elderly care and how these assessments outcomes are related to quality of life, as there mostly should be a negative relationship. There is a risk that pain are under diagnosed among persons with cognitive impairment. AIM: The aim was to describe and compare pain prevalence among nursing home residents (1) using different pain assessment methods (2) in relation to cognitive status and to (3) examine associations between pain and quality of life or well-being. METHODS: A cross-sectional correlational design was used, participants were 213 nursing home residents and data were collected through interviews using standardised protocols. Instrument used were Katz index of ADL, Mini-Mental-State-Examination, Quality of Life in Late-Stage Dementia scale, WHO-5 well-being index, Numeric Rating Scale and Doloplus-2 scale. RESULTS: The results showed high pain prevalence, but no significant difference based on cognitive level. Pain classification at the individual level varied somewhat when different instruments are used. The results indicated that use of a single-item proxy-measure for pain tends to show higher pain prevalence and was not statistically significant related to quality of life. The relationship with quality of life was statistically significant when self-rated pain instruments or multi-component observation were used. CONCLUSIONS: The study shows that it is difficult to estimate pain in residents living at nursing homes and that it continues to be a challenge to solve. Self-rated pain should be used primarily to assess pain, and a multi-component observation scale for pain should be used when residents are cognitively impaired. Both self-rated pain and multi-component observation also support the well-known link between pain and quality of life. Single-item proxy assessments should only be used in exceptional cases.

A multifaceted intervention for evidence-based pressure ulcer prevention: a 3 year follow-up.

AIM: To assess sustainability of an intervention used to implement pressure ulcer prevention. BACKGROUND: The Promoting Action on Research Implementation in Health Service, framework was used to develop an intervention aimed to implement evidence-based pressure ulcer prevention in a hospital setting. A short-term follow-up showed that significantly more patients received pressure ulcer prevention. A qualitative process evaluation gave support that the intervention and the implementation process changed the understanding and approach to working with pressure ulcer prevention from treating to preventing. METHOD: The study had a sequential mixed method approach, combining quantitative and qualitative data. For the quantitative data, baseline and short-term follow-up (6-8 months) data reported in an initial study were compared with long-term follow-up (36-42 months) data (n = 259 patients). For the qualitative data, interviews with registered nurses (n = 20), assistant nurses (n = 7) and first-line managers (n = 5) were performed. RESULTS: The performance of pressure ulcer prevention was sustained 3 years from its conception. The number of patients with pressure ulcers was reduced (P = 0.021). Systematic work with quality measurements, support from first-line managers, internal facilitation, collaboration and pressure ulcer prevention skills could explained the sustainability. Obstacles to achieve high-quality pressure ulcer prevention were inadequate communication, high workloads and high rates of new and substitute nurses. CONCLUSION: Three different components for sustainability on the micro-level are described; benefits for the patients, the need for routinization and development over time. Threats to sustainability are described as factors on the macro-level. There needs to be collaboration in the healthcare organization from the micro-to-macro levels, and committed experienced nurses are needed to obtain high-quality sustainable pressure ulcer prevention.

Caring in nursing homes to promote autonomy and participation.

BACKGROUND:: Autonomy and participation are threatened within the group of older people living in nursing homes. Evidence suggests that healthcare personnel act on behalf of older people but are still excluding them from decision-making in everyday care. OBJECTIVE:: The purpose was to describe registered nurses' experience of caring for older people in nursing homes to promote autonomy and participation. RESEARCH DESIGN:: A descriptive design with a phenomenological approach was used. Data were collected by semi-structured individual interviews. Analysis was inspired by Giorgi's method. PARTICIPANTS AND RESEARCH CONTEXT:: A total of 13 registered nurses from 10 nursing homes participated. ETHICAL CONSIDERATIONS:: Ethical approval was obtained from the Regional Research Ethics Committee. Informed consent was achieved and confidentiality guaranteed. FINDINGS:: The essence of caring for older people in nursing homes to promote autonomy and participation consisted of registered nurses' awareness of older people's frailty and the impact of illness to support health and well-being, and awareness of acknowledgement in everyday life and trusting relationships. Paying attention to older people by being open to the persons' wishes were aspects that relied on registered nurses' trusting relationships with older people, their relatives and surrounding healthcare personnel. The awareness reflected challenges in caring to promote older people's right to autonomy and participation in nursing homes. Registered nurses' strategies, hopes for and/or concerns about development of everyday life in nursing homes were revealed and mirrored their engagement in caring for older people. DISCUSSION AND CONCLUSION:: Awareness of older people's frailty in nursing homes and the importance of maintained health and well-being were described as the main source for promoting autonomy and participation. Everyday life and care in nursing homes needs to be addressed from both older people's and healthcare personnel's perspectives, to promote autonomy and participation for residents in nursing homes.

Systematic pain assessment in nursing homes: a cluster-randomized trial using mixed-methods approach.

BACKGROUND: Chronic pain affects nursing home residents' daily life. Pain assessment is central to adequate pain management. The overall aim was to investigate effects of a pain management intervention on nursing homes residents and to describe staffs' experiences of the intervention. METHODS: A cluster-randomized trial and a mixed-methods approach. Randomized nursing home assignment to intervention or comparison group. The intervention group after theoretical and practical training sessions, performed systematic pain assessments using predominately observational scales with external and internal facilitators supporting the implementation. No measures were taken in the comparison group; pain management continued as before, but after the study corresponding training was provided. Resident data were collected baseline and at two follow-ups using validated scales and record reviews. Nurse group interviews were carried out twice. Primary outcome measures were wellbeing and proxy-measured pain. Secondary outcome measures were ADL-dependency and pain documentation. RESULTS: Using both non-parametric statistics on residential level and generalized estimating equation (GEE) models to take clustering effects into account, the results revealed non-significant interaction effects for the primary outcome measures, while for ADL-dependency using Katz-ADL there was a significant interaction effect. Comparison group (n = 66 residents) Katz-ADL values showed increased dependency over time, while the intervention group demonstrated no significant change over time (n = 98). In the intervention group, 13/44 residents showed decreased pain scores over the period, 14/44 had no pain score changes ≥ 30% in either direction measured with Doloplus-2. Furthermore, 17/44 residents showed increased pain scores ≥ 30% over time, indicating pain/risk for pain; 8 identified at the first assessment and 9 were new, i.e. developed pain over time. No significant changes in the use of drugs was found in any of the groups. Nursing pain related documentation was sparse. In general, nurses from the outset were positive regarding pain assessments. Persisting positive attitudes seemed strengthened by continued assessment experiences and perceptions of improved pain management. CONCLUSION: The implementation of a systematic work approach to pain issues in nursing homes indicates that an increased awareness, collaboration across and shared understanding among the team members of the pain assessment results can improve pain management and lead to decreased physical deterioration or the maintenance of physical and functional abilities among NH residents. However, pain (proxy-measured) and wellbeing level did not reveal any interaction effects between the groups over time. TRIAL REGISTRATION: The study was registered in ISRCTN71142240 in September 2012, retrospectively registered.

Getting evidence-based pressure ulcer prevention into practice: a process evaluation of a multifaceted intervention in a hospital setting.

AIMS AND OBJECTIVES: To describe registered nurses', assistant nurses' and first-line managers' experiences and perceptions of a multifaceted hospital setting intervention focused on implementing evidence-based pressure ulcer prevention. BACKGROUND: Pressure ulcer prevention is deficient. Different models exist to support implementation of evidence-based care. Little is known about implementation processes. DESIGN: A descriptive qualitative approach. METHOD: Five focus-group nurse interviews and five individual first-line manager interviews were conducted at five Swedish hospital units. Qualitative content analysis was used. RESULT: The findings support that the intervention and the implementation process changed the understanding and way of working with pressure ulcer prevention: from treating to preventing. This became possible as 'Changed understanding enables changed actions - through one's own performance and reflection on pressure ulcer prevention'. Having a common outlook on pressure ulcer prevention, easy access to pressure-reducing equipment, and external and internal facilitator support were described as important factors for changed practices. Bedside support, feedback and discussions on current results increased the awareness of needed improvements. CONCLUSION: The multifaceted intervention approach and the participants' positive attitudes seemed to be crucial for changing understanding and working more preventatively. The strategies used and the skills of the facilitators need to be tailored to the problems surrounding the context. Feedback discussions among the staff regarding the results of the care provided also appear to be vital. RELEVANCE TO CLINICAL PRACTICE: It is crucial that dedicated facilitators are involved to promote the implementation process. A preventative mindset should be strived for. Creating an implementation plan with an outcome and a process evaluation should be emphasised. It is important to give the staff regular feedback on the quality of care and on those occasions allocate time for discussion and reflection.

Preceptors' reflections on their educational role before and after a preceptor preparation course: A prospective qualitative study.

During clinical practice, preceptors play an important educational role in helping nursing students become secure and effective practitioners. For this educational role they need adequate preparation. The aim of the present prospective study was to describe preceptors' experiences of their educational role before and after attending a university preceptor preparation course. This 7.5-credit, Master's level course is offered on a part-time basis and covers one semester. The theoretical approach was self-directed and reflective learning. Twentyseven preceptors participated in group interviews before and after the course, and data were analyzed using qualitative content analysis. The findings revealed a shift in preceptors' perceptions. Their view of the educational role changed from being characterized by individual experiences and notions to being guided by personal and formal demands. Before the course, the lack of sufficient preconditions for preceptorship predominated, whereas after the course participants described ways of creating such preconditions. Before the course, the supervisory process was described as teaching, whereas after the course it was described as a learning process for students. Using reflective learning in a preceptor preparation course can develop and strengthen preceptors' view of their educational role and help them manage and create the preconditions for preceptorship.

A longitudinal qualitative study of health care personnel's perceptions of simultaneous implementation of three risk assessment scales on falls, malnutrition and pressure ulcers.

AIMS AND OBJECTIVES: In this study, the aim was to understand health care personnel's expectations and experiences of participating in an intervention aimed at the implementation of three assessment scales for fall injuries, malnutrition and pressure ulcers, and the performance of preventive measures in these areas over the period of 18 months. BACKGROUND: Fall injuries, malnutrition and pressure ulcers among older people are challenging issues for caregivers at different levels in the health care system. DESIGN: A descriptive design with a qualitative approach was used to follow health care personnel before, during and after implementation of a care prevention intervention. METHODS: Twelve health care personnel with different professions at the hospital, primary care and municipal care levels participated in a preventive care introduction. Seminars were held at four occasions, with assignments to be completed between seminars. Lectures and group discussions were performed, and three risk assessment scales were introduced. The participants were interviewed before, during and after the introduction. Manifest and latent content analysis were used. RESULTS: The main results are presented in the theme 'Patient needs are visualised through a gradually developed shared understanding' and in five categories. The work approach of performing three risk assessments simultaneously was perceived as positive and central to ensuring quality of care; it was not, however, perceived as unproblematic. CONCLUSION: The participants as well as health care team members showed a positive attitude towards and described the advantages of being given opportunities for shared understanding to improve patient safety and to provide structure for the provision of good care. RELEVANCE TO CLINICAL PRACTICE: The managerial approach of listening to and acting on issues stressed by health care personnel is important to ensure ongoing and future improvement initiatives.

Getting evidence-based pressure ulcer prevention into practice: a multi-faceted unit-tailored intervention in a hospital setting.

The aim of the study was to evaluate whether a multi-faceted, unit-tailored intervention using evidenced-based pressure ulcer prevention affects (i) the performance of pressure ulcer prevention, (ii) the prevalence of pressure ulcers and (iii) knowledge and attitudes concerning pressure ulcer prevention among registered and assistant nurses. A quasi-experimental, clustered pre- and post-test design was used. Five units at a hospital setting were included. The intervention was based on the PARIHS framework and included a multi-professional team, training and repeated quality measurements. An established methodology was used to evaluate the prevalence and prevention of pressure ulcers. Nurses' knowledge and attitudes were evaluated using a validated questionnaire. A total of 506 patients were included, of whom 105 patients had a risk to develop pressure ulcer. More patients were provided pressure ulcer prevention care (P = 0·001) and more prevention care was given to each patient (P = 0·021) after the intervention. Corresponding results were shown in the group of patients assessed as being at risk for developing pressure ulcers. Nurses' knowledge about pressure ulcer prevention increased (P < 0·001). Positive attitudes towards pressure ulcer prevention remained high between pre- and post-test surveys. This multi-faceted unit-tailored intervention affected pressure ulcer prevention. Facilitation and repeated quality measurement together with constructed feedback of results seemed to be the most important factor for pressure ulcer prevention.

Life memories and the ability to act: the meaning of autonomy and participation for older people when living with chronic illness.

There is a lack of knowledge about how older people living with chronic illness describe the meaning of autonomy and participation, indicating a risk for reduced autonomy and participation in their everyday life. The purpose of this study was to describe the meaning of autonomy and participation among older people living with chronic illness in accordance with their lived experience. The design was descriptive with a phenomenological approach guided by Giorgi's descriptive phenomenological psychological method. Purposive sampling was used, and 16 older people living with chronic illness who lived in an ordinary home participated in individual interviews. The findings showed that the meaning of autonomy and participation among the older people emerged when it was challenged and evoked emotional considerations of the lived experience of having a chronic illness. It involved living a life apart, yet still being someone who is able, trustworthy and given responsibility--still being seen and acknowledged. The meaning of autonomy and participation was derived through life memories and used by the older people in everyday life for adjustment or adaption to the present life and the future. Our conclusion is that autonomy and participation were considered in relation to older people's life memories in the past, in their present situation and also their future wishes. Ability or disability is of less importance than the meaning of everyday life among older people. We suggest using fewer labels for limitations in everyday life when caring for older people and more use of the phrase 'ability to act' in different ways, based on older people's descriptions of the meaning of autonomy and participation.

Pressure ulcer knowledge of registered nurses, assistant nurses and student nurses: a descriptive, comparative multicentre study in Sweden.

The aim of this study was to describe and compare the knowledge of registered nurses (RNs), assistant nurses (ANs) and student nurses (SNs) about preventing pressure ulcers (PUs). PU prevention behaviours in the clinical practice of RNs and ANs were also explored. A descriptive, comparative multicentre study was performed. Hospital wards and universities from four Swedish county councils participated. In total, 415 participants (RN, AN and SN) completed the Pressure Ulcer Knowledge Assessment Tool. The mean knowledge score for the sample was 58·9%. The highest scores were found in the themes 'nutrition' (83·1%) and 'risk assessment' (75·7%). The lowest scores were found in the themes 'reduction in the amount of pressure and shear' (47·5%) and 'classification and observation' (55·5%). RNs and SNs had higher scores than ANs on 'aetiology and causes'. SNs had higher scores than RNs and ANs on 'nutrition'. It has been concluded that there is a knowledge deficit in PU prevention among nursing staff in Sweden. A major educational campaign needs to be undertaken both in hospital settings and in nursing education.

Nursing preceptors' experiences of two clinical education models.

Preceptors play an important role in the process of developing students' knowledge and skills. There is an ongoing search for the best learning and teaching models in clinical education. Little is known about preceptors' perspectives on different models. The aim of the study was to describe nursing preceptors' experiences of two clinical models of clinical education: peer learning and traditional supervision. A descriptive design and qualitative approach was used. Eighteen preceptors from surgical and medical departments at two hospitals were interviewed, ten representing peer learning (student work in pairs) and eight traditional supervision (one student follows a nurse during a shift). The findings showed that preceptors using peer learning created room for students to assume responsibility for their own learning, challenged students' knowledge by refraining from stepping in and encouraged critical thinking. Using traditional supervision, the preceptors' individual ambitions influenced the preceptorship and their own knowledge was empathized as being important to impart. They demonstrated, observed and gradually relinquished responsibility to the students. The choice of clinical education model is important. Peer learning seemed to create learning environments that integrate clinical and academic skills. Investigation of pedagogical models in clinical education should be of major concern to managers and preceptors.

Older patients referred by community nurses to emergency departments--a descriptive cross-sectional follow-up study in a Swedish context.

OBJECTIVES: The objective of this study was to examine on what extent nursing home (NH) older patients aged 75 or older, referred to hospitals by registered nurses (RNs) in the community, utilise the emergency department (ED) over a 1-year period and for what reason. A further objective was to identify factors that may explain these referrals. METHODS: A cross-sectional follow-up study, examining older patients' disabilities, resources and needs, was carried out in a county in Sweden. Assessments were made using Residents Assessment Instrument/Minimum Data Set, among 719 individuals in 24 NHs and the RNs' documentation were followed. RESULTS: The result showed that of 719 residents, 209 accounted for 314 referrals to an ED over the 1-year period. No gender differences were observed. The main reasons for referrals were falls (23%), cardiovascular problems (16%), gastrointestinal problems (12%) and infections (11%). Most of the referrals (65%) were made on weekdays during daytime hours. In 62% of the cases, there had been a consultation with a physician prior to the referral. The nursing documentation was poor in connection with the referral. CONCLUSION: Older patients with dementia diseases were significant less refereed and questions are raised whether this group is undetected and undertreated, and therefore, it is important with further investigation.

District nurses' self-reported clinical activities, beliefs about and attitudes towards obesity management.

AIM: To describe district nurses' self-reported clinical activities, beliefs about and attitudes towards obesity management; and to examine associations between the variables. BACKGROUND: Obesity is increasing worldwide and primary care could play a central role in the management. METHODS: Questionnaire data were collected from 247 nurses in 33 centres. RESULTS: The most common activities performed weekly were; advice about physical activity (40.1%) and general lifestyle advice (34.8%). However, nearly one third seldom/never performed these activities. Approximately half seldom/never performed BMI assessment and even fewer waist circumference (78.1%). Values for the factors Importance of obesity and Personal effectiveness were skewed towards a positive view and Negative view close to neutral. Multivariate analysis revealed that nurses with specialized tasks, longer working experience and higher perceived personal effectiveness performed more clinical activities. CONCLUSION: Managers need to make efforts to engage all personnel in obesity management; and strategies to increase self-efficacy are called for.

Nursing students' perceptions of clinical supervision: the contributions of preceptors, head preceptors and clinical lecturers.

AIM: The aims of the study were 1) to investigate to what extent nursing students were satisfied with the supervision provided by facilitators (preceptor, head preceptor, and clinical lecturer), 2) to compare nursing students' ratings of facilitators' contribution to supervision as supportive and challenging, and 3) to examine relationships between facilitators' supportive and challenging behavior in supervision and nursing students' perception of fulfillment of expected learning outcomes in clinical education. BACKGROUND: Although there are many studies on support of students in clinical education, few have addressed this from the students' point of view or made comparisons between different facilitators. METHODS: A cross-sectional survey study was conducted during April to November 2010, where 107 nursing students, from a university in central Sweden, answered a questionnaire about supervision immediately after their period of clinical education. RESULTS: Supportive behavior in supervision was rated higher by students for all facilitator groups as compared with challenging behavior. The students rated preceptors and clinical lecturers as more supportive than head preceptors and clinical lecturers as providing more challenges than the two other facilitator groups. Supportive and challenging behavior in supervision explained 39% of the variance in students' overall learning outcomes. However, the regression coefficient was only significant for students' ratings of supportive behavior for the preceptor. CONCLUSIONS: Nursing students were satisfied with facilitators' supervision and by their contribution to fulfillment of overall learning outcomes. Comparisons showed that preceptors in a higher degree were perceived as supportive while clinical lecturers were perceived as more important as challengers for critical thinking, reflection and exchange of experiences between students. The model of supervision seems to be promising, but the roles across facilitators need to be made clearer, especially the head preceptor's role, which seemed to be the most unclear role in this model.

What are the structural conditions of importance to preceptors' performance?

BACKGROUND: Preceptors play a critical role in the process of developing nursing students' knowledge, skills and ability to make independent and critical judgments, however relatively little is known about what aspects are associated with nurses' performance as preceptors. OBJECTIVES: To investigate structural conditions and professional aspects of potential importance to nurses' perceptions of their performance as preceptors, and to evaluate the validity and reliability of a questionnaire measuring nurses' perceptions of being a preceptor. METHODS: The study had a correlational design. Total population sampling (N=1720) in a county council district in central Sweden was used to screen for nurses with recent preceptor experience, 933 nurses responded (response rate 54%), of those 323 nurses fulfilled the inclusion criteria. The present findings are based on data from 243 of these subjects. Data were collected with a questionnaire and analyzed using multiple regressions analyses, exploratory factor analyses and reliability coefficients. RESULTS: The results show that aspects such as receiving feedback on the function as a preceptor, being able to plan and prepare the clinical education period, receiving support from unit managers and having specific supervision education explain 31% of nurses' overall view of their performance as preceptors. However, structural conditions and professional experiences could not explain preceptors' use of reflection and critical thinking when acting as preceptors. These findings are discussed within the framework of Kanter's structural theory of power in organizations. Further, the psychometric evaluation showed that the questionnaire is a valid and reliable instrument for measuring nurses' structural conditions for and perceptions of their performance as preceptors. CONCLUSIONS: Structural conditions such as feedback and support seemed to strengthen nurses' general view of their performance as preceptors but did not seem to facilitate nurses' work toward the aim of higher education and helping nursing students develop critical thinking.

Registered nurses' attention to and perceptions of pressure ulcer prevention in hospital settings.

AIM: To describe how registered nurses perform, document and reflect on pressure ulcer prevention in a specific nurse-patient care situation, as well as generally, on hospital wards. BACKGROUND: Registered nurses should provide safe and qualified pressure ulcer prevention, but pressure ulcers remain a problem. Compliance with evidence-based guidelines impedes pressure ulcer formation. DESIGN: A descriptive design with a multimethods approach. METHOD: Nine registered nurses at three wards and hospitals participated. The registered nurses were observed in a specific nurse-patient care situation with patients at risk for pressure ulcers. Interviews followed and patients' records were reviewed. Quantitative and qualitative data analysis methods were used. RESULTS: Pressure ulcer prevention performed by the registered nurses was dependent on the cultural care, which ranged from planned to unplanned prevention. Diversity was found in compliance with evidence-based guidelines across the wards. Although all patients involved were at risk and the nurses described pressure ulcer prevention as basic care, the nurses' attention to prevention was lacking. Few prevention activities and no structured risk assessments using risk assessment tools were observed, and few care plans were identified. The lack of attention was explained by registered nurses' trust in assistant nurses' knowledge, and prevention was seen as an assistant nurse task. CONCLUSION: Registered nurses paid little attention to pressure ulcer prevention among patients at risk. The planned and unplanned care structures affected the prevention. The nurses trusted and largely delegated their responsibility to the assistant nurses. RELEVANCE TO CLINICAL PRACTICE: Evidence-based pressure ulcer prevention is fundamental to patient safety. Care quality is created in situations where patients and care providers meet. How registered nurses work with pressure ulcer prevention, their role and communication, particularly with assistant nurses, should be of major concern to them as well as to healthcare managers.

Deficient knowledge of multidrug-resistant bacteria and preventive hygiene measures among primary healthcare personnel.

AIM: This paper is a report of a study conducted to describe primary healthcare personnel's knowledge of multidrug-resistant and preventive hygiene measures. BACKGROUND: The group of patients at risk for multi-drug resistant bacteria is largely cared for in primary care. Knowledge of multidrug-resistant and hygiene preventive measures among primary healthcare personnel is therefore essential. METHOD: A descriptive and comparative questionnaire survey among primary healthcare personnel was performed in 2008. In total, five urban and rural primary healthcare centres situated in one county in central Sweden were included. Convenient sampling was used and 10 physicians, 38 district nurses and 10 nursing assistants participated. Knowledge/medical facts concerning multidrug-resistant and hygiene preventive measures were investigated and data were analysed using a quantitative approach. RESULTS: Knowledge/medical facts concerning several aspects of multidrug-resistant bacteria, particularly Extended-Spectrum-Beta-Lactamase producing bacteria, were deficient as was knowledge of different aspects of hygiene preventive measures. Physicians showed significantly better results than district nurses and nursing assistants did. Awareness of proper hand-washing as an effective preventive method and use of aprons in nursing care was high among all participants. Staff who knew they had cared for these patients had significantly better results than the others did. CONCLUSION: Our findings suggest that evidence-based education of multidrug-resistant and hygiene preventive measures, in primary health with subsequent follow-ups should become a prioritized clinician and management concern. Research is needed that focus implementation of evidence-based educations, staff attitudes and responsibilities related to the work with patients at risk of multidrug-resistant bacteria.

Malnutrition in elder care: qualitative analysis of ethical perceptions of politicians and civil servants.

BACKGROUND: Few studies have paid attention to ethical responsibility related to malnutrition in elder care. The aim was to illuminate whether politicians and civil servants reason about malnutrition in elder care in relation to ethical responsibility, and further about possible causes and how to address them. METHOD: Eighteen elected politicians and appointed civil servants at the municipality and county council level from two counties in Sweden were interviewed. They worked at a planning, control and executive level, with responsibility for both the elder care budget and quality of care. Qualitative method was used for the data analysis. RESULTS: Two themes emerged from their reasoning about malnutrition related to ethical responsibility. The theme assumed role involves the subthemes quality of care and costs, competent staff and govern at a distance. Old and ill patients were mentioned as being at risk for malnutrition. Caregivers were expected to be knowledgeable and stated primary responsible for providing adequate nutritional care. Extended physician responsibility was requested owing to patients' illnesses. Little was reported on the local management's role or on their own follow-up routines. The theme moral perception includes the subthemes discomfort, trust and distrust. Feelings of discomfort concerned caregivers having to work in a hurried, task-oriented manner. Trust meant that they believed for the most part that caregivers had the competence to deal appropriately with nutritional care, but they felt distrust when nutritional problems reappeared on their agenda. No differences could be seen between the politicians and civil servants. CONCLUSION: New knowledge about malnutrition in elder care related to ethical responsibility was illuminated by persons holding top positions. Malnutrition was stressed as an important dimension of the elder care quality. Governing at a distance meant having trust in the staff, on the one hand, and discomfort and distrust when confronted with reports of malnutrition, on the other. Distrust was directed at caregivers, because despite the fact that education had been provided, problems reappeared. Discomfort was felt when confronted with examples of poor nutritional care and indicates that the participants experienced failure in their ethical responsibility because the quality of nutritional care was at risk.

Master's level in primary health care education - students' and preceptors' perceptions and experiences of the alteration in the clinical areas.

BACKGROUND: Many Western European countries are undergoing reforms with changes in higher education according to the Bologna declaration for Higher European Education Area. In accordance with these changes, the Master's degree was introduced in specialist nurse education in Sweden in 2007, and as a result changed the curriculum and modified theoretical and clinical areas. The aim of this study was to investigate students' and preceptors' perceptions and experiences of Master's level education in primary health care with a focus on the clinical area. METHODS: A descriptive design and qualitative approach was used. Interviews with ten students and ten preceptors were performed twice, before and after the clinical practice period. Interviews were audio-recorded, transcribed verbatim and themes formulated. RESULTS: Students perceived alteration in the content of the education at the Master's level such as more independence and additional assignments. The preceptors perceived benefits with the Master's level but were unsure of how to transform theoretical and abstract knowledge into practice. Writing the Master's thesis was seen by students to take time away from clinical practice. For some students and preceptors the content of the Master's level clinical practice area was experienced as vague and indistinct. The students had not expected supervision to be different from earlier experiences, while preceptors felt higher demands and requested more knowledge. Both students and preceptors perceived that education at the Master's level might lead to a higher status for the nurses' profession in primary health care. CONCLUSIONS: Students and preceptors experienced both advantages and disadvantages concerning the change in specialist nurse education in primary health care at the Master's level. The altered educational content was experienced as a step forward, but they also questioned how the new knowledge could be used in practice. The relevance of the Master's thesis was questioned. Supervision was seen by students as an introduction to the work of the district nurses' work. Preceptors perceived high demands and did not feel enough qualified for student supervision. Both groups considered it an advantage with the change in education that could result in higher status for nurses working in primary health care.

Caregivers' strong commitment to their relationship with older people.

The aim of the present study was to describe caregivers' good as well as bad experiences of working with older people. The study was based on five focus group interviews. One theme emerged from a latent content analysis: strong commitment to the relationship. This theme functioned as a thread of underlying meaning throughout the entire interpretative process of 48 caregivers' experiences of work. A delicate relationship existed that could be vulnerable and could reveal itself in feelings of lack of knowledge, guilt and fear. The caregivers' committed relationship to the older adults created independency in the ways in which they protected the older people's needs. Further studies are needed that focus on caregivers' transition from dependency to independency. The findings highlight the importance of clinical supervision to personal development and identity, and to promoting caregivers' self-esteem and maintaining a committed relationship. Commitment is a deep human feeling, and it should be promoted in order to maintain and further develop quality care for older adults.