Exploring Existential Loneliness Among Frail Older People as a Basis for an Intervention: Protocol for the Development Phase of the LONE Study.

BACKGROUND: International research concerning end-of-life issues emphasizes the importance of health care professionals (HCPs) being prepared to deal with existential aspects, like loneliness, in order to provide adequate care. The last phase of life is often related to losses of different kinds, which might trigger feelings of isolation in general and existential loneliness (EL) in particular. There is a large body of research concerning loneliness among older people in general, but little is known about the phenomenon and concept of EL in old age. OBJECTIVE: This study aims to describe the framing, design, and first results of the exploratory phase of an intervention study focusing on EL among older people: the LONE study. This stage of the study corresponds to the development phase, according to the Medical Research Council framework for designing complex interventions. METHODS: The LONE study contains both theoretical and empirical studies concerning: (1) identifying the evidence base; (2) identifying and developing theory through individual and focus group interviews with frail older people, significant others, and HCPs; and (3) modeling process and outcomes for the intervention. This project involves sensitive issues that must be carefully reviewed. The topic in itself concerns a sensitive matter and the study group is vulnerable, therefore, an ethical consciousness will be applied throughout the project. RESULTS: The results so far show that EL means being disconnected from life and implies a feeling of being fundamentally separated from others and the world, whether or not one has family, friends, or other close acquaintances. Although significant others highlighted things such as lack of activities, not participating in a social environment, and giving up on life as aspects of EL, the older people themselves highlighted a sense of meaningless waiting, a longing for a deeper connectedness, and restricted freedom as their origins of EL. The views of HCPs on the origin of EL, the place of care, and their own role differed between contexts. CONCLUSIONS: The studies focusing on identifying the evidence base and developing theory are published. These results will now be used to identify potential intervention components, barriers, and enablers for the implementation of an intervention aimed at supporting HCPs in encountering EL among older people. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/13607.

Existential loneliness: An attempt at an analysis of the concept and the phenomenon.

BACKGROUND: According to ethical guidelines, healthcare professionals should be able to provide care that allows for the patients' values, customs and beliefs, and the existential issues that are communicated through them. One widely discussed issue is existential loneliness. However, much of the debate dealing with existential loneliness concludes that both the phenomenon and the concept are quite vague. AIM: To clarify what constitutes existential loneliness, and to describe its lived experiences. A further aim was to provide a definition of existential loneliness that can function as a tool for identifying the phenomenon and for differentiating it from other kinds of loneliness. METHOD: A literature review including theoretical and empirical studies. Different search strategies were used to gather the articles included in the study. The analysis of the empirical studies had an interpretative approach. The articles were also analysed with the aim of providing a definition of existential loneliness. This was done by means of criteria such as language, uniqueness, theory and usefulness. This study is not empirical and does therefore not require an ethics review. RESULTS: The analysis resulted in two main characteristics. The first one was perceiving oneself as inherently separated (disconnected) from others and from the universe. The second one brings out emotional aspects of EL, such as isolation, alienation, emptiness and a feeling of being abandoned. The empirical findings were divided into two categories: experiences of EL and circumstances in which EL arises. A definition of EL is also suggested, based on the two main characteristics identified. CONCLUSION: In order to meet patients' needs, it is an ethical duty for healthcare staff to be able to recognise experiences of EL, that is, to communicate with the patients about these experiences in an appropriate manner. This in turn demands knowledge about existential issues and skills to deal with them.

Contrasts in older persons' experiences and significant others' perceptions of existential loneliness.

BACKGROUND: As frail older people might have difficulties in expressing themselves, their needs are often interpreted by others, for example, by significant others, whose information health care staff often have to rely on. This, in turn, can put health care staff in ethically difficult situations, where they have to choose between alternative courses of action. One aspect that might be especially difficult to express is that of existential loneliness. We have only sparse knowledge about whether, and in what way, the views of frail older persons and their significant others concerning existential loneliness are in concordance. OBJECTIVE: To contrast frail older (>75) persons' experiences with their significant others' perceptions of existential loneliness. METHODS: A case study design was chosen for this study. Individual interviews with frail older persons (n = 15) and interviews with their significant others (n = 19), as well as field notes, served as a basis for the study. A thematic analysis was used to interpret data. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the principles of research ethics. FINDINGS: The findings showed three themes: (1) Meaningless waiting in contrast to lack of activities, (2) Longing for a deeper connectedness in contrast to not participating in a social environment and (3) Restricted freedom in contrast to given up on life. DISCUSSION: Knowledge about the tensions between older persons' and their significant others' views of existential loneliness could be of use as a basis for ethical reflections on the care of older people and in the encounter with their significant others. CONCLUSION: It is of importance that health care professionals listen to both the frail older person and their significant other(s) and be aware of whose voice that the care given is based on, in order to provide care that is beneficial and not to the detriment of the older person.

Hoping to reach a safe haven - Swedish families' lived experience when a family member is diagnosed with breast cancer.

PURPOSE: When a woman is diagnosed with breast cancer, it affects all family members. Therefore, the aim of this study was to elucidate family members lived experience when a family member is diagnosed with breast cancer. METHOD: The study had a hermeneutic phenomenological design including individual conversational interviews conducted face-to-face with six women with breast cancer and their family members at two different points of time, in order to elucidate families' lived experience, both as individuals and as a unit, from each family member's perspective. RESULTS: Living as a family in the presence of breast cancer is a challenging endeavour to regain an ordinary, safe life, hoping to reach a safe haven. The families felt that life as they knew it had disappeared and they were fumbling in the dark, trying to find support and guidance on their path to ordinary life. The family members were pursuing balance by attempting to keep the family together and maintaining a positive attitude while battling against fear and treatment-related side effects. Finally, the families were struggling with guilt and inadequacy, due to their difficulties in communicating the emotional distress that the illness brought upon them, at the same time as they felt abandoned by the healthcare professionals. CONCLUSIONS: Families experience an unmet need of information and support, which implies that healthcare professionals may want to acknowledge and include the family already at the time of diagnosis in order to help them endure and cope with the distressing experience and thus increase their wellbeing.

Older persons' existential loneliness, as interpreted by their significant others - an interview study.

BACKGROUND: In order to better understand people in demanding medical situations, an awareness of existential concerns is important. Studies performed over the last twenty years conclude that when dying and death come closer, as in the case with older people who are stricken by infirmity and diseases, existential concerns will come to the fore. However, studies concerning experiences of existential loneliness (EL) are sparse and, in addition, there is no clear definition of EL. EL is described as a complex phenomenon and referred to as a condition of life, an experience, and a process of inner growth. Listening to someone who knows the older person well, as significant others often do, may be one way of learning more about EL. METHODS: This study is part of a larger research project on EL, the LONE study, where EL is explored through interviews with frail older people, their significant others and health care professionals. The aim of this study was to explore frail older (>75) persons' EL, as interpreted by their significant others. The study is qualitative and based on eighteen narrative interviews with nineteen significant others of older persons. The data was analysed using Hsieh and Shannon's conventional content analysis. RESULTS: According to the interpretation of significant others, the older persons experience EL (1) when they are increasingly limited in body and space, (2) when they are in a process of disconnecting, and (3) when they are disconnected from the outside world. CONCLUSION: The result can be understood as if the frail older person is in a process of letting go of life. This process involves the body, in that the older person is increasingly limited in his/her physical abilities. The older person's long-term relationships are gradually lost, and finally the process entails the older person's increasingly withdrawing into him- or herself and turning off the outside world. The result of this study is consistent with previous research that has shown that EL is a complex phenomenon, but the implications of this research include a deepened understanding of EL. In addition, the study highlights the interpretations of significant others.

Being a haematopoietic stem cell donor for a sick sibling: Adult donors' experiences prior to donation.

BACKGROUND: There is a lack of knowledge about sibling stem cell donors' experiences pre-donation and the waiting period before the donation might have been long. The donors and their corresponding sibling recipients were simultaneously included in two different interview studies. The results from the recipient study have been presented in a separate paper. PURPOSE: The aim was to explore the experiences of being a stem cell donor for a sibling, prior to donation. METHOD: Ten adult sibling donors were interviewed prior to stem cell donation. The interviews were digitally recorded, transcribed verbatim and subjected to qualitative content analysis. RESULTS: The main theme Being a cog in a big wheel describes the complex process of being a sibling donor prior to donation, covering a mixture of emotions and thoughts. The four subthemes Being available, Being anxious, Being concerned and Being obliged cover the various experiences. The sibling donors' experiences are influenced by the quality of the relationship with the sick sibling. CONCLUSIONS: Sibling stem cell donors go through a complex process once they have accidentally got involved in. They have been asked to become a donor; it was not a voluntary choice. In caring for sibling stem cell donors the nurses should be aware of the complexity of the process they experience and take into consideration their personal situation and needs. Providing optimal care for both sibling donors and their corresponding recipients is a challenge, and further improvement and exploration are needed.

Attitudes to and Experiences of Physical Activity among Migrant Women from Former Yugoslavia: -- a qualitative interview study about physical activity and its beneficial effect on heart health, in Malmö, Sweden.

BACKGROUND: Many risk factors for heart disease can be reduced by lifestyle modifications such as physical activity, but the attitude to and the knowledge about the beneficial effect of physical activity vary among the population. Migrant women are reported to have a higher BMI and to be less physically active than the Swedish-born women. In order to motivate them to participate in physical activity it is necessary to understand that they are not a homogenous group, and thus their knowledge about, needs for, and attitude to physical activity have to be examined. Aim: The aim of the study was to explore structural and individual factors working either as barriers against or as motivation for a change towards higher levels of physical activity and a healthy lifestyle. Furthermore, the aim was to investigate if the migration had changed the women's level of physical activity and what would be required to increase it. METHOD: Seven women from Bosnia living in Malmö, Sweden, were interviewed by means of a semi-structured interview guide. The data was analyzed using Burnard's content analysis method. RESULTS: The findings were presented in two categories, namely, "barriers against physical activity" and "motivational factors for physical activity". With regard to the category "barriers against physical activity", the move to Sweden had led to losses and shifts in lifestyles for the women. The greatest lifestyle changes were reported among women who had moved from rural areas in Bosnia to urban areas in Sweden. They found it troublesome to reach the same activity level in Sweden and expressed a greater need to do so. Earlier negative experiences or no experiences at all, of performing physical activity, as well as the winter climate, were seen as obstacles to being active. All the women prioritized family, work, school, and club activities above physical activity. With respect to the category "motivational factors for physical activity", it was found that physical activity could help improve their mental balance, and the women also considered the possibility of losing weight. CONCLUSION: The study showed that although these migrant women had difficulties finding appropriate and realistic physical activities, and prioritized family activities, they desired to be more physically active, even if the climate was seen as a hindrance. They also reported that physical activity could be a means to achieve better mental health as well as weight loss. Politicians ought to allocate funding, and public health worker to focus more on and enable this high risk group of immigrant women to become more physical active. They should also be informed about their increased risk of myocardial infarction. This, to stimulate increased physical activity among them and in ought to be in co-working with their own immigrant organization.

Conceptual development of "at-homeness" despite illness and disease: a review.

Only one empirical study, the one by Zingmark, Norberg and Sandman published in 1995, explicitly focuses on at-homeness, the feeling of being metaphorically at-home, as a particular aspect of wellness. However, other studies reveal aspects of at-homeness, but if or how such aspects of at-homeness are related to each other is unclear. For this reason, the aim was to review Scandinavian nursing research related to at-homeness in the context of wellness-illness in severe and long-term conditions in order to take a step towards conceptual clarification of "at-homeness." The review included interpretive studies related to severe and long-term illness conducted in Sweden: 10 original articles and 5 doctoral theses. "At-homeness" was found to be a contextually related meaning of wellness despite illness and disease embedded in the continuum of being metaphorically at-home and metaphorically homeless. This was characterized by three interrelated aspects and four processes: being safe through expanding-limiting experiences of illness and time, being connected through reunifying-detaching ways of relating, and being centred through recognition-non-recognition of oneself in the experience and others giving-withdrawing a place for oneself. This conceptualization is to be regarded as a step in conceptual clarification. Further empirical investigation and theoretical development of "at-homeness" are needed. The conceptualization will be a step of plausible significance for the evaluation of interventions aimed at enhancing wellness for people with severe long-term illness, such as the frail elderly, and people with chronic illness or palliative care needs.

Having a sibling as donor: patients' experiences immediately before allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Allogeneic hematopoietic stem cell transplantation (HSCT) offers a potential cure for a variety of diseases but is also associated with significant risks. With HSCT the donor is either a relative, most often a sibling, or an unrelated registry donor. PURPOSE: The aim was to explore patients' experiences, immediately before transplantation, regarding having a sibling as donor. METHOD: Ten adult patients with sibling donors were interviewed before admission for HSCT. The interviews were digitally recorded, transcribed verbatim and subjected to qualitative content analysis. RESULTS: The main theme Being in no man's land is a metaphor for the patients' complex situation with its mixture of emotions and thoughts prior to transplantation. The three subthemes Trust in the sibling donor, Concern about others and Loss of control cover the various experiences. The patient's experiences are influenced by their personal situation and the quality of the relationship with the sibling donor. While patients feel secure in having a sibling donor, they are dependent for their survival on the cell donation and feel responsible for the donor's safety during donation. These emotions intensify the patients' sense of dependency and loss of control. CONCLUSIONS: In caring for HSCT patients the nurses should be aware of the complexity of the patients' situation and keep in mind that having a sibling donor might imply extra pressure, including a sense of responsibility. Caring for both patients and sibling donors optimally is a challenge, which needs further improvement and exploration.

Registered nurses' perceptions of their professional work in nursing homes and home-based care: a focus group study.

BACKGROUND: In Sweden, as well as in most industrialised countries, an increasing older population is expected to create a growing demand for health care staff. Previous studies have pointed to lack of proficient medical and nursing staff specialised in geriatric care, which poses serious threats to the care of a vulnerable population. At the same time, there are studies describing elderly care as a low-status career choice, attracting neither nurses nor student nurses. Judging from previous research it was deemed important to explore how nurses in elderly care perceive their work, thus possibly provide vital knowledge that can guide nurse educators and unit managers as a means to promote a career in elderly care. OBJECTIVE: The aim of the present study was to illuminate how nurses, working in nursing homes and home-based care, perceived their professional work. METHOD: This was a qualitative study using focus groups. 30 registered nurses in seven focus groups were interviewed. The participants worked in nursing homes and home-based care for the elderly in rural areas and in a larger city in southern Sweden. The interviews were analysed in line with the tradition of naturalistic inquiry. RESULTS: Our findings illustrate how nurses working in elderly care perceived their professional work as holistic and respectful nursing. Three categories of professional work emerged during analysis: (1) establishing long-term relationships, (2) nursing beyond technical skills, and (3) balancing independence and a sense of loneliness. CONCLUSIONS: The findings are important as they represent positive alternatives to the somewhat prevailing view on elderly care as depressing and undemanding. Nurse educators might use the key aspects as good examples, thus influencing student nurses' attitudes towards elderly care in a positive way. Elderly care agencies might find them helpful when recruiting and retaining nurses to a much needed area.

The use of drama to support reflection and understanding of the residents' situation in dementia care: a pilot study.

BACKGROUND: One key aspect of person-centredness is striving to understand both the patients' experiences and behaviours from their perspective. These aspects are precisely those that staff in dementia care highlight as causing them most difficulty because the people in their care have major problems expressing themselves. There is thus a need to develop a method to help the staff to achieve interpretation through reflection. AIM: The aim of this study was to explore the use of drama as a tool to support reflection among staff working in the residential care of people with dementia. DESIGN: A qualitative evaluation of a programme consisting of three drama sessions with staff working in residential care (n = 10 nurse assistants). METHODS: Data comprised observations and tape recordings of the sessions, the researchers' reflections after each session and a focus-group interview with the participants. The texts were analysed using qualitative content analysis. RESULTS: The analysis showed that: (i) the exercises stimulate reflection about daily caring practice; (ii) the participants must receive extensive information about the purpose of the sessions; (iii) the research team must secure the defined frames and conditions and have practical knowledge about caring for people with dementia and (iv) the management needs to be stable, committed and supportive. CONCLUSION: Drama seems to be a valid tool to aid reflection, but several adjustments are needed concerning both the content of the sessions and the methodology. When designing a larger intervention study, it would be preferable to the sessions to be combined with staff support to effect changes in care provision resulting from their increased awareness of the residents' situation and experience. IMPLICATIONS FOR PRACTICE: Our results showed that drama can be a means to enhance reflection among staff in residential care for people with dementia. Further research is however needed concerning the effects for the staff's situation and nursing care quality.

Pain relief at the end of life: nurses' experiences regarding end-of-life pain relief in patients with dementia.

Patients with dementia receive suboptimal palliative care, and this patient group is at risk to have pain at the end of life. Because communicative impairments are common in this patient group, nurses play an important caregiver role in identifying, assessing, and relieving patients' pain. This study aimed to describe nurses' experiences regarding end-of-life pain relief in patients with dementia. This descriptive exploratory qualitative study was based on seven semistructured interviews. Burnard's content analysis inspired the data analysis. Two main categories were identified: (1) nurses' experience of difficulties concerning pain relief and (2) nurses' experience of resources concerning pain relief. Nurses experienced difficulties, such as feeling of powerlessness because of difficulties in obtaining adequate prescriptions for analgesics, ethical dilemmas, feeling of inadequacy because analgesia did not have the desired effect, and a feeling of not being able to connect with the patient. Factors, including knowledge about the patient, professional experience, utilization of pain assessment tools, interpersonal relationships, and interprofessional cooperation, served as resources and enabled end-of-life pain relief. The results of this study highlight the complexity of pain relief in patients with dementia at the end of life from a nursing perspective. The inability of patients with dementia to verbally communicate their pain makes them a vulnerable patient group, dependent on their caregivers. Knowing the life story of the patient, professional experience, teamwork based on good communication, and use of a pain assessment tool were reported by the nurses to improve pain relief at the end of life for patients with dementia.

Being in want of control: Experiences of being on the road to, and making, a suicide attempt.

Attempted suicide is a risk factor for future suicidal behaviour, but understanding suicidality from the perspective of people who have experienced attempted suicide is limited. The aim of the study was to explore the lived experience of being suicidal and having made a suicide attempt, in order to identify possible implications for health care professionals. Semi-structured individual interviews were held with 10 persons shortly after they attempted suicide and were analysed through qualitative content analysis. The participants' experience of being suicidal and of having attempted suicide could be described as "Being on the road towards suicidal action", which culminated in an experience of either chaos or turned off emotions, "Making sense of the suicide attempt", and "Opening the door to possible life lines". An overall theme, "Being in want of control", captured their all-embracing lack of sense of control and was seen in relation to different aspects of oneself, overall life-situation, the immediate suicide attempt situation and in the outlook on the future. Being in want of control may be a relevant and general feature of being suicidal. People who have attempted suicide need more adequate help to break vicious circles before they reach a point of no return and enter an acute suicidal state of mind. Patients' experience-based knowledge is highly important to listen to and use clinically as well as theoretically when constructing suicide prevention programs.

A spider in the web: role of the palliative care nurse specialist in Uganda--an ethnographic field study.

BACKGROUND: Palliative care is not a priority in developing countries. Hospice Africa Uganda (HAU), where nurses complete a course in clinical palliative care, is considered a model for other African countries. AIM: To explore the role of the palliative care nurse specialist (PCNS) in Uganda. METHODS: This ethnographic field study uses observations, interviews, and group interviews. PARTICIPANTS: In total, 20 participants are included in this study. RESULT: The role of the palliative care nurse specialist is multifaceted. Beyond prescribing drugs, their role is to deliver holistic care. They encounter numerous challenges in their work, but they also have the possibility to improve the quality of the patient's life.

End-of-life care for old people: a review of the literature.

The aim of this study was to make an inventory of various aspects of end-of-life care of the old people. An additional aim was to illuminate gaps in existing knowledge. A systematic literature review focusing on intervention studies was carried out. Three concepts were of special interest: end-of-life care, palliative care, and terminal care. The result encompassed 29 studies, and the articles were grouped together under 4 headings: education and support for close relatives, education and support for staff, education and support for patients, and articles dealing with care planning. The result highlights the need for further research regarding end-of-life care in geographical and cultural settings that differ from those in the USA, needs of old people (ie, 80+), preferences concerning end-of-life care, and the effect of adjusted and generalizable palliative care models.

Ethical considerations of refusing nutrition after stroke.

The aim of this article is to analyse and discuss the ethically problematic conflict raised by patients with stroke who refuse nutritional treatment. In analysing this conflict, the focus is on four different aspects: (1) Is nutritional treatment biologically necessary? (2) If necessary, is the reason for refusal a functional disability, lack of appetite or motivation, misunderstanding of the situation or a genuine conflict of values? (3) If the latter, what values are involved in the conflict? (4) How should we deal with the different kinds of refusal of nutritional treatment? We argue that patients' autonomy should be respected as far as possible, while also considering that those who have suffered a stroke might re-evaluate their life as a result of a beneficial prognosis. However, if patients persist with their refusal, health care professionals should force nutritional treatment only when it is clear that the patients will re-evaluate their future life.

Living with cancer and perception of care: Icelandic oncology outpatients, a qualitative study.

AIM: This qualitative study was set out to explore oncology outpatient experiences of having cancer, to illuminate coping strategies and to explore perceptions of care and service provided while treated for cancer. MATERIALS AND METHODS: Thirty patients undergoing chemotherapy or radiotherapy were consecutively selected for the study in three oncology outpatient clinics in Iceland; mean age was 55 years. All participants gave written consent but five dropped out of the study. Twenty-five semi-structured single interviews were conducted and analysed using manifest and latent content analysis. RESULTS: The descriptive level of the text could be understood as: (a) getting cancer: alarming experience; (b) coping: balancing life as it was before cancer against present situation to achieve normality; (c) satisfaction: encountering caring behaviour enhances satisfaction and well being. Each of the categories encompassed variation of subcategories. All the categories were summarised in the core category: "Being in the alarming situation of getting cancer evokes a strong need to maintain normality and keep uncertainty at distance with support from caring and sensitive encounters." This reflected patients' overall experiences of being diagnosed with cancer, how they coped and their perception of quality of care while going through treatment. CONCLUSION: Reactions to the diagnosis of cancer indicate strong emotional reactions. A strong will to handle the situation and determination to maintain normality in life was prominent. Establishment of positive patient-health care professional relationships, caring encounters, faith, believing in treatment and support from family was highly valued as support and giving hope.

Icelandic cancer patients receiving chemotherapy or radiotherapy: does distance from treatment center influence distress and coping?

The aim was to investigate psychologic distress and coping strategies in cancer patients during the time of chemotherapy or radiotherapy treatment and to compare those who lived close to the treatment center and those who had to stay away from home for treatment. Participants were 22 to 91 years old, 57% female patients, from 3 oncology outpatient clinics in Iceland. They were assessed with the Brief Symptom Inventory (BSI 18) and The Ways of Coping-Cancer Version (WOC-CA). Significantly higher scores were only found in somatic symptoms for patients who lived close to the treatment center than those who did not. Women had significantly higher scores on overall psychologic distress, depression, anxiety, social support, and behavioral and cognitive escape-avoidance compared with men. Significantly more depression and anxiety was found in the age group 22-45 years than the age group older than 70 years. Living alone, stress (WOC-CA), behavioral escape-avoidance, and distancing were shown to be significantly associated with psychologic distress. Having to stay away from home for treatment does not seem to affect cancer patients' psychologic well-being or the way they cope, whereas type of treatment has. Psychological distress is higher in female cancer patients than male and in younger patients (22-45 years) compared with older ones (>70 years). Also, findings indicate that coping strategies can influence distress.

From cure to palliation: agreement, timing, and decision making within the staff.

Important issues in the transition from curative treatment to palliative care are agreement, timing, and decision making. A survey of 309 nurses and 415 physicians in Sweden showed that 61% of the nurses and 83% of the physicians thought agreement was current practice. None said that the decisions were made too early, but 19% of the nurses and 14% of the physicians thought that they often were made too late. Very few respondents stated that such decisions are changed, 0% and 1%, respectively. More than half of the informants made detailed comments on such transitions indicating that awareness and flexibility are desirable to make well-informed decisions. Three themes that emerged from the analysis concerning the decision to stop curative treatment and focus on palliative care were that the staff members should (if possible) make such decisions in agreement and should sometimes make the decisions earlier and that well-based reasons are required to make changes.

Everyday ethical problems in dementia care: a teleological model.

In this article, a teleological model for analysis of everyday ethical situations in dementia care is used to analyse and clarify perennial ethical problems in nursing home care for persons with dementia. This is done with the aim of describing how such a model could be useful in a concrete care context. The model was developed by Sandman and is based on four aspects: the goal; ethical side-constraints to what can be done to realize such a goal; structural constraints; and nurses' ethical competency. The model contains the following main steps: identifying and describing the normative situation; identifying and describing the different possible alternatives; assessing and evaluating the different alternatives; and deciding on, implementing and evaluating the chosen alternative. Three ethically difficult situations from dementia care were used for the application of the model. The model proved useful for the analysis of nurses' everyday ethical dilemmas and will be further explored to evaluate how well it can serve as a tool to identify and handle problems that arise in nursing care.