To Örebro University

Background: Patient participation is well understood by health care professionals but not many studies have focused on the older adults and their perceptions of patient participation.

Aim and Objectives: To report an analysis of the concept of participation from the perspective of the older adult. Design: Concept analysis.

Methods: An integrative review approach was undertaken and the searches were limited from January 2003 to December 2014, guiding question was; “what constitutes patient participation according to the older adult?”

Results: Through the eyes of the older adults, a two-way communication should be initiated by the staff. Equality and sharing power between older adults and staffs was perceived as a precondition. Been given time was an essential issue, implying that older adults wished to have enough time from staffs and be in the right context surrounded by the appropriate environment in order to experience participation.

Conclusion: In order to experience participation for older adults, it is important that the health care professionals are aware of how and in what ways they can contribute to participation among older adults. The need or wish to create participation is not enough; the health care professional needs to see and understand participation through the older adult’s eyes. Thus, a person-centered nursing approach is relevant for the health care professional in order to both give and maintain the experience of participation to the older adult.

Aim and objectives: To develop and test feasibility and acceptability of an interactive ICT-platform integrated in a tablet for collecting and managing patient reported concerns of older adults in home care.

Background: Using different ICT-applications, e.g. interactive tablets for self-assessment of health and health issues, based on health monitoring as well as other somatic and psychiatric monitoring systems may improve quality of life, staff and patient communication and feelings of being reassured. The European Commission hypothesize that introduction of ICT-applications to the older population will enable improved health. However, evidence-based and user-based applications are scarce.

Design: The design is underpinned by the Medical Research Council's complex intervention evaluation framework. A mixed-method approach was used combining interviews with older adults and healthcare professionals, and logged quantitative data.

Methods: In cooperation with a health management company, a platform operated by an interactive application for reporting and managing health related problems in real time was developed. Eight older adults receiving home care were recruited to test feasibility. They were equipped with the application and reported three times weekly over four weeks, and afterwards interviewed about their experiences. Three nurses caring for them were interviewed. The logged data was extracted as a coded file.

Results: The older adults reported as instructed, in total 107 reports (mean 13). The most frequent concerns were pain, fatigue and dizziness. The older adults experienced the application as meaningful with overall positive effects as well as potential benefits for the nurses involved.

Conclusions The overall findings in this study indicated high feasibility among older adults using the ICT-platform. The study's results support further development of the platform, as well as tests in full-scale studies and in other populations.

Relevance to practice: An ICT-platform increased the older adults' perception of involvement and facilitated communication between the patient and nurses.

The number of people reaching old age is increasing rapidly, challenging the society and healthcare to promote healthy and meaningful aging. There is, and has been for a few years, a big interest in collecting patient reported outcomes (PROs) as a base for clinical management. Information and communication technology (ICT) and assistive technology in elderly care increase and may facilitate the care of older adults as they are moved from nursing homes to private homes. An ICT-platform for reporting health issues with immediate access to self-care advice and direct communication with healthcare professionals has been developed. The overall aim of this project is to evaluate the effects of the interactive ICT-platform regarding optimal functionality and participatory care. The project will be conducted in three phases: development of the ICT-platform, evaluating feasibility and evaluation of effects. The platform is unique by integrating interactive components for direct clinical management and needs to be thoroughly evaluated before implementation in daily practice. It is hypothesized that by using an interactive ICT-platform, it will promote participatory care and enhance the communication between older adults and their professional carers. The platform will be further developed, as well as test in a full-scale study.

AIM: To describe the impact of mental health on the ability to function optimally among older adults experiencing mental health issues.

DESIGN: This study had a descriptive qualitative design.

METHODS: Six older females with a Hospital Anxiety and Depression Scale (HADS) score of ≥8 on either of the subscales (depression or anxiety) participated in individual interviews. All data were analysed using a phenomenological approach influenced by Giorgi.

RESULTS: The phenomenological analysis led to a structured synthesis comprising the following three themes: (a) life situations affecting mental health, (b) consequences of mental health in everyday life and (c) strategies for maintaining mental health.

BACKGROUND: Aging is characterized by loss of function and represents a perspective that puts the focus on the negative aspects of aging. Thus, it is fundamental to shift the focus from loss of function to maintaining good health and personal satisfaction through life; in other words, to promote optimal functionality at a level appropriate for older adults. However, it is not yet known what constitutes optimal functionality from the older adult's own perspective.

OBJECTIVE: To explore the concept of optimal functionality in old age from the older adult's perspective (ie, people over 65 years of age) in industrialized Western countries.

METHODS: We undertook a scoping review and searched two electronic databases (PubMed and the Cumulative Index to Nursing and Allied Health Literature [CINAHL]) from January 2002 to July 2013 for scientific studies, using the key search term personal satisfaction. In total, 25 scientific studies were analyzed.

RESULTS: Only six of the included articles applied a qualitative methodology. By analyzing the results of these articles, three major themes were identified as cornerstones in the concept of optimal functionality at old age: 1) self-related factors (eg, mental well-being); 2) body-related factors (eg, physical well-being); and 3) external factors equal to demographic and environmental factors.

CONCLUSION: There is a lack of qualitative studies in the current literature, and hence of what constitutes optimal functionality from the older adult's perspective. The results outlined in this review identify three cornerstones (self-related factors, body-related factors, and external factors) of what constitutes optimal functionality at old age. However, it is vital that these findings are taken further and are evaluated through qualitative studies to reflect older adults' opinions.

Background: Decreased independence and loss of functional ability are issues regarded as inevitably connected to old age. This ageism may have negative influences on older adults' beliefs about aging, making it difficult for them to focus on their current ability to maintain a good health. It is therefore important to change focus towards promoting Optimal Functionality (OF). OF is a concept putting the older adult's perspective on health and function in focus, however, the concept is still under development. Hence, the aim was to extend the concept of optimal functionality in various groups of older adults.

Methods: A qualitative study was conducted based on focus group discussions (FGD). In total 6 FGDs were performed, including 37 older adults from three different groups: group 1) senior athletes, group 2) free living older adults, group 3) older adults living in senior living homes. All data was transcribed verbatim and analyzed following the process of deductive content analysis.

Results: The principal outcome of the analysis was "to function as optimally as you possibly can", which was perceived as the core of the concept. Further, the concept of OF was described as multifactorial and several new factors could be added to the original model of OF. Additionally the findings of the study support that all three cornerstones comprising OF have to occur simultaneously in order for the older adult to function as optimal as possible.

Conclusions: OF is a multifaceted and subjective concept, which should be individually defined by the older adult. This study further makes evident that older adults as a group are heterogeneous in terms of their preferences and views on health and should thus be approached as such in the health care setting. Therefore it is important to promote an individualized approach as a base when caring for older adults.

Previously, fear in adolescents with cancer has been sparsely described from an emic perspective. The aim of this study was to illuminate fear in adolescents with personal experience of cancer. The participants were six adolescent girls between the age of 14 and 16 years who were no longer under active treatment for cancer but still went for regular check-ups. Open interviews were conducted. Data were analysed according to the phenomenological hermeneutic method. In the result one main theme was identified: `an embodied fear — a threat to the personal self'. This theme was built up by three separate but intertwined themes: `experiencing fear related to the physical body', `experiencing existential fear' and `experiencing fear related to the social self'. In the comprehensive understanding the fear was interpreted from youth cultural aspects as well as a holistic perspective. The importance of professionals taking the whole person and their situation into account when meeting the fear is underlined.

Background: Previously fears in adolescents with cancer has been identified in relation to medical procedures, death, altered appearance and as having an overall influence on life, but to our knowledge young people's perspectives on dealing with fear have not been previously investigated.

Purpose: To examine adolescents' perspectives on dealing with cancer related fear.

Methods and sample: Six girls participated in qualitative interviews focussing on their fear and and how they dealt with it. Data were analysed by means of qualitative content analysis.

Results: The results revealed two perspectives. First, the adolescents' own personal battle with fear. Second, they reported that they were not alone with their fear, as they shared it with significant others. An environment characterized by emotional presence helped them to deal with their fear, as well as prevented it from occurring.

Conclusions: There is a need for staff and parents to be vigilant to the adolescents' need to feel cared for and allow them the opportunity to deal with their own fear, as at times they want to manage in their own way. Young patients have resources to cope with their fears and therefore should not be viewed as victims, but as young people with a great amount of competence, who benefit from a supportive environment.

BACKGROUND: Although registered nurses (RNs) play a central role in the care of older persons, their work in elderly care has historically been described as "low status" in nursing. This is especially problematic due to the global issue of RN turnover, but there is still little evidence of how to change this trend. Better understanding is needed of the reasons why RNs work in elderly care, as well as knowledge of whether these reasons have changed over time.

AIM: The aim was to explore the meaning of working in elderly care, over time, from the perspective of RNs.

METHOD: We interviewed thirteen RNs working in nursing homes, six of them in 2000 and the remaining seven in 2012, and analysed the resulting data using Interpretive Description.

RESULTS: The results show similarities and differences over time in the RNs' reasoning about the meaning of their work with older persons, from a focus on obstacles to a view of opportunities.

CONCLUSION: An RN's intention to continue working in elderly care might be based on their beliefs; their view of older people, and their experiences of being able to influence the care. Managing this knowledge could be an essential factor in reversing the historical trend of RN work in elderly care being seen as low status, and the increasing turnover in such nurses. Our results could stimulate reflection on daily care and beliefs about caring for older persons.

Background: Leaders play an essential role in the health care of older adults. The leadership role has changed over the years because of new demands in providing care for older adults with multiple chronic conditions, as well as a lack of resources.

Aim: The aim of this study was to describe formal leaders’ views over time on their leadership and the competence among staff in care of older adults.Method: Individual interviews and focus group discussions with leaders in care of older adults were conducted with a total of 46 formal leaders in 2000 (n=20) and 2011 (n=26). The analysis took a qualitative approach, using interpretative description.

Results: The leaders’ descriptions of leadership encompassed two different views on leadership over time, from “I as a leader” to “We together”. The leaders interviewed in 2011 saw practical wisdom (phronesis) as a central aspect of staff competence. Throughout the interviews, a greater focus on personal characteristics was seen over time.

Conclusions: Differences over time in views of the leaders’ role and staff competence, especially the increased focus on personal characteristics, may have an impact on the health care provided to older adults. This is particularly true if formal education is not prioritized. Strategies within organizations and continuing development and education must take these changes into consideration

Many of the increasing number of community-dwelling older adults will need increased healthcare in the future. By characterising gut health and its association with wellbeing and nutrient intake in this population, we aim to recognise areas along the gut-brain axis through which the health of community-dwelling older adults might be promoted. In this cross-sectional observational study, validated questionnaires were used to assess gut health, nutrient intake, and wellbeing in 241 community-dwelling older adults (>= 65 years old). In total, 65% of the participants experienced at least one gastrointestinal symptom, of which females had more abdominal pain and constipation, while the oldest old (i.e., >= 80 years old) had more diarrhoea. Increased gastrointestinal symptoms correlated with more stress, anxiety, depression, and a decreased quality of life, in addition to dyspepsia which correlated with a lower E% of protein. Most of the participants did not reach the recommended intake for protein, fibre and polyunsaturated fats. Males had a lower intake of protein (E%) and fibre (g/MJ) than females, and the oldest old had a lower E% of protein than younger older adults. In conclusion, our results demonstrate that gastrointestinal symptoms are common, and most of the study participants had an imbalanced macronutrient intake, which could be a target for future possible dietary interventions to improve overall health.

The aim was to describe nursing home (NH) caregivers' work experiences while receiving education and clinical supervision for 2 years. Working in elder care seems to be losing its attraction especially with organizational changes, cutbacks and changes in work place conditions. Clinical supervision has been reported to increase job satisfaction and creativity. Semi-structured interviews from caregivers working at an NH in Sweden were conducted, at the start and again at 12 and 24 months. At about 12 months the caregivers were informed of planned cutbacks. Content analysis was the method used to analyse the interviews from seven caregivers who participated throughout the entire period. Findings show that the value of a caring milieu was one category generated by the subcategories: experiences related to work activities and changes, and experiences related to relationships. The value of knowledge was the other category that was influenced by the experiences related to the different backgrounds and the experiences related to increased knowledge gained from the support through education and clinical supervision. The categories contained positive as well as negative influences on care. The initial focus on practical duties associated with the opening of the NH shifted towards caregiver activities with the elders they spoke warmly about. After 2 years the caregivers' willingness to care continued despite their disappointment in the worsened working conditions. The main theme that resulted was: Despite shattered expectations a willingness to care for elders remained. Continued education and clinical supervision seems to be one factor behind the retained willingness. These findings demonstrate that support and caregiver involvement in educational programmes are important during times of change and when disappointments arise in the workplace.

FLACKMAN B, HANSEBO G and KIHLGREN A. Nursing Inquiry 2009; 16: 82-91 Struggling to adapt: caring for older persons while under threat of organizational change and termination notice Organizational changes are common in elder care today. Such changes affect caregivers, who are essential to providing good quality care. The aim of the present study was to illuminate caregivers' experiences of working in elder care while under threat of organizational change and termination notice. Qualitative content analysis was used to examine interview data from 11 caregivers. Interviews were conducted at three occasions during a two-year period. The findings show a transition in their experiences from 'having a professional identity and self-confidence', to 'being a professional in a threatening situation caused by someone else' and to 'struggling to adapt to a changed working environment as a person and a professional'. The caregivers experienced a loss of pride and satisfaction. Previous literature indicates that this may have consequences for the quality of care and that employees may be at risk of negative health effects. However, the caregivers continued to struggle, doing their best to complete their duties. The study has implications for high-level decision-makers, managers and caregivers in similar work-life situations in that it deals with factors that facilitate or impede similar transitions.

Background: Reorganization and downsizing can disrupt a competent staff and conflicts can arise between what the employee is being asked to do and their knowledge and competences. Reduced job satisfaction among nursing home staff with increased workload and strain can occur.                                                                                                   

Aim and Objectives: The aim was to investigate the organizational climate and prevalence of burnout symptoms among caregivers over time in three Swedish nursing homes (NH I-III) undergoing organizational changes, while education and clinical supervision were provided. Design: The study design combines qualitative and quantitative methods in a longitudinal two-year follow-up project in NH I-III.                                                                   

Methods: Support through education and clinical supervision was provided for caregivers only at NH I and NH II. At NH I-III caregiver self-assessments and interviews were completed and analysed three different times. Results: NH I revealed improvement and increased innovation over time, while NH II showed a decline with no ability to implement new knowledge. NH III retained a more status quo.                                                                             

Conclusions: Organizational changes and cutbacks, occurring at different times, appeared to cause major stress and frustration among the three personnel groups. They felt guilty about not meeting their perceived obligations, seemed to have lost pride in their work but kept struggling. The changes seemed to over-shadow attempts to improve working conditions through education and clinical supervision initially.                                               

Implications for practice: It will be important to learn from reorganizations and the consequences they will have for the staff and quality of care. Important topics for future research are to study financial cutbacks and changes in organizational processes in care of older people to be able to develop a more person centered care for older people.

In Sweden, the operators at emergency dispatch centres are responsible for allocating resources (e.g. ambulances, fire brigade, police) in response to calls. We analysed situations that the emergency operators experienced as difficult and their reflections on how they managed them. Interviews were conducted with all 16 emergency operators at a centre that serves a population of 275,000 and receives about 700,000 emergency calls annually. A phenomenological-hermeneutic approach was used for the analysis. Situations that operators experienced as difficult were characterized by uncertainty, communication difficulties and insufficient resources. Skills, knowledge and experience were regarded as important in the management of these situations, as were personal qualities such as sensitivity, insight, empathy and intuition. The emergency operators stated that they needed more guidance, feedback and education in their work. This would lead to an increased sense of certainty, which would lead to decreased stress and a better outcome for those in need.

INTRODUCTION: Transportation of critically ill patients, intra- or inter-hospital, always involves risks when resources are limited. With aeromedical transports, additional risk factors are incurred. The physiological effects of altitude, when both pressure and density decline, can lead to hypobaric hypoxia and gases trapped in body cavities will expand and cause stress on biological tissue.

AIM: The aim of this study was to explore the experiences of nurse and physician specialists in Sweden undertaking long distance aeromedical transport of critically ill patients, with a flight time of more than two hours.

METHOD: A qualitative approach with a descriptive design. Thirteen recorded semi-structured interviews with physician and nurse specialists were analyzed using inductive qualitative content analysis.

RESULTS: One overall theme emerged, To be one step ahead to ensure patient safety in the air; with three categories 1) With the patient in focus, 2) To be part of a team and concerned about patient safety and 3) To be in need of recovery.

CONCLUSION: This study demonstrates the challenges with long distance aeromedical transport of critically ill patients. The healthcare personnel make decisions and actions to be one step ahead to ensure patient safety. This isolated work is improved with experience, education, training and good communication skills.

Aims and objectives: To explore registered nurses' mentorship practices of first-year nursing students in nursing home placements.

Background: Enabling nursing students to develop professional competence through clinical placements relies heavily on registered nurses' mentorship practices. Despite renewed interest in nursing homes as an important clinical placement setting, studies are scarce on registered nurses' mentorship practices in this context.

Design: An exploratory, qualitative mixed-methods design.

Methods: The data consisted of 126 h' observation of two registered nurse mentor-student dyads, supplemented by in-depth interviews (n = 12) with registered nurse mentors. The data were collected in three Norwegian nursing homes and analysed using content analysis. The consolidated criteria for reporting qualitative research (COREQ) checklist were used to report the findings.

Results: The registered nurses' mentorship practices of first-year nursing students in nursing home clinical placement were characterised by (1) variability and uncertainty in pedagogical supervisory approaches, (2) lack of management support and engagement of staff members in supervision, (3) lack of supervisory continuity and (4) a peripheral role in formal assessment discussions.

Conclusions: A marginal nursing home context, alongside a mismatch between registered nurses' roles and first-year students' learning objectives, introduces considerable vulnerability that impedes effective mentorship practices. Targeted efforts to enhance mentorship practices in nursing homes are warranted to promote full use of the learning potential in this context. Developing and testing educational interventions is necessary to effectively enhance registered nurses' pedagogical competence, alongside engagement and support from nurse managers and nurse educators.

Relevance to clinical practice: This study provides insight into barriers to effective mentorship practices of first-year nursing students in nursing home placements. These barriers warrant attention from nursing home managers and nurse education institutions towards improvements that enhance effective mentorship practices vital for students' learning, professional growth and future recruitment to care for older people.

Background: When an older patient is discharged from a hospital in Sweden, a care plan in cooperation with the patient should be made through coordinated care planning (COCP). Previous research has described difficulties in the discharge process; consequently, it is important to develop additional knowledge and investigate both whether and how patients are given the opportunity to participate in COCP. The aim of the present study was to determine if older patients are given the opportunity to participate in COCP meetings, and if so, what characterizes these meetings.

Method: This qualitative, descriptive study is based on non-participant observation of interactions between older patients and care staff at six COCP meetings. The data collected were analyzed using directed content analysis and critical discourse analysis (CDA).

Results: The main findings indicate a lack of patient participation in all the COCP meetings held at the hospital. The dialogues in that context were less information intensive, and a professional perspective dominated. The situation in advanced home care (AHC) was the opposite; already from the outset, it was evident that the patient was the chief informant and that the patient’s perspective predominated during the dialogues.

Conclusions: General differences in the way the dialogues were initiated and in how they progressed were observed between the hospital and AHC. Due to both shortage of time in health care today and financial issues, it is important to find solutions that incorporate the older patient’s experiences as well as professional knowledge.

AIMS AND OBJECTIVES: To explore the experiences of using an app among older people with home-based health care and their nurses.

BACKGROUND: Few information and communication technology innovations have been developed and tested for older people with chronic conditions living at home with home-based health care support. Innovative ways to support older people's health and self-care are needed.

DESIGN: Explorative qualitative design.

METHODS: For 3 months to report health concerns, older people receiving home-based health care used an interactive app, which included direct access to self-care advice, graphs and a risk assessment model that sends alerts to nurses for rapid management. Interviews with older people (n = 17) and focus group discussions with home care nurses (n = 12) were conducted and analysed using thematic analysis.

RESULTS: The findings reveal that a process occurs. Using the app, the older people participated in their care, and the app enabled learning and a new way of communication. The interaction gave a sense of security and increased self-confidence among older people. The home care nurses viewed the alerts as appropriate for the management of health concerns. However, all participants experienced challenges in using new technology and had suggestions for improvement.

CONCLUSIONS: The use of an app appears to increase the older people's participation in their health care and offers them an opportunity to be an active partner in their care. The app as a new way to interact with home care nurses increased the feeling of security. The older people were motivated to learn to use the app and described potential use for it in the future.

IMPLICATIONS FOR PRACTICE: The use of an app should be considered as a useful information and communication technology innovation that can improve communication and accessibility for older people with home-based health care.

AIM AND OBJECTIVES: To acquire knowledge regarding the contents to be implemented in an interactive ICT-platform perceived to be relevant to health and self-care among older persons based on the literature, healthcare professionals and the older persons themselves.

BACKGROUND: The growing ageing population places demands on the healthcare system to promote healthy ageing and to strengthen the older person's self-care ability. This requires innovative approaches to facilitate communication between the older person and healthcare professionals, and to increase the older person's participation in their care. An information and communication technology-platform (ICT-platform) could be used for this purpose, but the content needs to be relevant to both the older persons and the healthcare professionals.

DESIGN: Descriptive qualitative design.

METHODS: This study was based on three samplings: a scoping review of the literature (n=20 articles), interviews with healthcare professionals (n=5), and a secondary analysis of interviews with older persons (n=8) and nursing assistants (n=7). The data were analysed using qualitative content analysis.

RESULTS: Four areas were identified to be of relevance to older persons' perceived health: frame of mind, having relationships and social activities, physical ability and concerns, and maintaining self-care. Self-care was described in the literature and by the healthcare professionals more than by the older persons.

CONCLUSIONS: The results show a concordance in the data samplings that give a clear indication of the areas relevant to older persons' health and self-care that can be integrated in an interactive ICT-platform for use in regular daily care assessments. Descriptions of self-care was limited indicating a possible gap in knowledge that requires further research.

RELEVANCE TO CLINICAL PRACTICE: Areas relevant to older persons' health and self-care could be used for regular assessment to support and promote healthy ageing.

Background: The increasing ageing population puts demands on society and particularly on health care system to promote a health related quality of life. Thus, it is necessary to develop strategies that promote self-care among older adults that enable them to live in their own homes as long as possible and to make them feel safe and involved in their care. In order to encourage their participation in their care, new innovative solutions are needed. The market of information-and communication technology (ICT)-based platforms directed to the health care arena has exploded during recent years. Despite the large range of products few are developed with interactive components. In collaboration within a multicenter research group and a Swedish health care company (Health Navigator) an ICT-platform is developed for use in a mobile phone or tablet that includes an interactive mobile application for reporting problems and concerns. This platform is unique through the real-time communication enabling rapid management of earlydetected problems.

Aim: The aim with the project is to evaluate an ICT-platform by older adults living in own homes with assistance from home care nurses in a community in Sweden.

Method: The study is prospective and has a mixed methods approach advocated for the evaluation of new technologies within healthcare. This includes a quantitative approach to evaluate effects, qualitative methods such as interviews and focus group discussions to evaluate how patients and health care professionals perceive the intervention. The design is underpinned by the Medical Research Council’s complex intervention evaluation framework. Thirty older adults >65 years or above, living in their own homes, with assistance from home care nurses have through an application in a tablet reported health status twice a week and when needed during three months. They have continuous access to evidence based self-care advice directly related to their reported problems and concerns. The risk assessment model sends alarms to involved nurses via text messaging (SMS). This initiates an interaction between the nurse and the older adult who is contacted by telephone to discuss the reported problems. Furthermore, the nurses in charge can also log into a web-interface and view the reports of the participants. Individually interviews with the older adults and focus groups interviews with nurses are conducted after the study period. Questionnaires are given to the older adults before intervention, after the study´s completed and after six months with primarily main outcomes as self-care, health literacy and well-being. A control group with older adults 65 years and above is used as a comparison.

Results: Preliminary results will be presented with focus on feasibility, acceptability and benefit of the ICT-platform from the perspective of older adults and home care nurses. Additional logged data on the frequency of symptom reports, alerts, and page views will also be presented.

Summary: An interactive ICT-platform is developed and used by older adults to report problems and concerns which enabling rapid management of early-detected problems. This study aims to evaluate the ICT-platform by thirty older adults living in own home with assistance from home care nurses.

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.

The aim of the present study was, by means of discussion highlighting ethical questions and moral reasonings, to increase understanding of the situations of caregivers and relatives of older persons living in a public nursing home in Sweden. The findings show that these circumstances can be better understood by considering two different perspectives: an individual perspective, which focuses on the direct contact that occurs among older people, caregivers and relatives; and a societal perspective, which focuses on the norms, values, rules and laws that govern a society. Relatives and caregivers thought that the politicians were sending out mixed messages: they were praising caregivers and relatives for their efforts, but at the same time the public health care sector was subjected to significant cutbacks in resources. Both caregivers and relatives were dissatisfied and frustrated with the present situation regarding the care of older persons in public nursing homes.

AIMS AND OBJECTIVES: The aim of the present study was to describe the relatives' experience concerning older family members living in special housing facilities.

BACKGROUND: During the 21st century, the relatives of older people and their efforts related to the care and nursing of older people have been observed. The interest in these relatives is because of factors such as demographic changes, where the number of older people has increased and the increasing gap between the resources that are available for geriatric care and the care needed for older people.

DESIGN: The present study has a descriptive design and is part of a project including 24 specific residences, called special housing facilities.

METHOD: The study focused on the narratives supplied by the relatives that were analysed using qualitative latent content analysis, an interpretative process where the researcher considers the content of the text.

RESULTS: The relatives' experience of having an older person in a special housing facility that emerged from the study, was expressed in one main theme: The relatives' struggle for an improved and just care for older people and four sub-themes: (i)'To trust in caregivers'; (ii) 'To be confirmed'; (iii) 'To trust in care'; (iv) 'To receive the kind of care that one considers one has the right to receive'.

CONCLUSIONS: The study shows that the relatives need more support and more opportunities, so that they can participate in the care. The study shows the relatives engagement in working for a just society's obligation towards the protection of older peoples rights and the staff's working conditions.

RELEVANCE TO CLINICAL PRACTICE: It is important that caregivers and management working with older people realize that they, together with them and their relatives, are a part of society and that all individuals are influenced by the discourse of that society.

BACKGROUND: In Sweden and internationally, little research has focused on the working situation of Enrolled Nurses and Nurses' Aides who form the majority of workers in geriatric care today. With this in mind, it is important to focus on how these occupational groups experience their working situation with older residents in municipal care.

AIMS AND OBJECTIVES: The aim of the study was to investigate the deeper meaning of work satisfaction and work dissatisfaction at a newly opened nursing home for older residents. The study focused on the narratives supplied by the caregivers at the nursing home. The participants included: one Registered Nurse, sixteen Enrolled Nurses, and three Nurses' Aides. All were directly involved in patient care.

DESIGN: The present study is part of a larger longitudinal study within the municipal geriatric care system in Sweden, with a quasi-experimental design.

METHOD: The interviews were analysed with a phenomenological-hermeneutic method inspired by the philosophy of Ricoeur.

RESULT: The caregivers experiences of work satisfaction and work dissatisfaction was expressed in four themes: (i) 'Experience of betrayal' describes how the staff felt let down in several ways; (ii) 'Experience of failing others' describes how the staff felt that they did not pay enough attention to older people, in several different ways; (iii) 'Experience of insufficiency' describes how the staff encountered overwhelming demands from several directions; (iv) 'Experience of work satisfaction' describes how the staff felt that they were given support in various ways. Each theme emerged from several subthemes that originated from the caregivers' narratives.

CONCLUSIONS: The study shows that the caregivers' experience of work dissatisfaction overshadows their experience of work satisfaction. It also suggests that their feelings of failing the older residents are connected to their own experiences of feeling betrayed.

RELEVANCE TO CLINICAL PRACTICE: The findings can be used when other nursing homes in municipal care are opened, as a means of preventing work dissatisfaction and increasing work satisfaction among future employees.

AIMS AND OBJECTIVES: The aim of the study was to investigate, from the narratives of nine enrolled nurses and one nurses' aide directly involved in patient care, the deeper meaning of work satisfaction and dissatisfaction when working with the older people.

BACKGROUND: Both nationally and internationally, there is little research documented regarding the working situation of the enrolled nurses and nurses' aides who make up the majority of care for older people today. With this in mind, it is important to focus on how these occupational groups experience their work with the older residents in municipal care, following a two-year intervention.

DESIGN: The study is part of a larger longitudinal study, with a quasi-experimental design within the municipal system of care for older people in Sweden. The investigation was carried out following a two-year intervention, which included: education, support and clinical supervision.

METHOD: The interviews were performed 12 and 24 months after start of the intervention and were analysed with a phenomenological-hermeneutic method inspired by Ricoeur's philosophy.

RESULTS: The findings from these narratives illustrated a change compared with the findings from the first interviews, when the nursing home had just opened. There was a shift from a dominance of dissatisfaction with work, to a dominance of work satisfaction and this was expressed in the following themes: experience of a changed perspective, experience of open doors, and experience of closed doors. Each theme emerged from several different subthemes and each subtheme that had been expressed in the caregivers' narratives was interpreted.

CONCLUSIONS: The study shows that the caregivers' experience of work satisfaction in the workplace exceeded their experience of dissatisfaction and that the intervention, consisting of: education, support, and supervision might have facilitated this positive development where the older residents were prioritized. It also shows that communication and understanding between management and staff had increased as the nursing home had opened.

RELEVANCE TO CLINICAL PRACTICE: The findings can be used to help to prevent work dissatisfaction, and thereby increase work satisfaction for caregivers working in nursing homes.

Introduction: The Swedish national guidelines for elderly care describe how older persons should be able to trust that their care is permeated with security. Different theoretical perspectives can be found that describe what creates security. Many studies have been done about security. However, few studies have explicitly asked older persons what security in nursing homes means to them.

Aim: The aim of the study was to describe how older persons in nursing homes talked and reflected about security in their daily lives.

Method: Nine older persons were interviewed in, in-depth interviews one to three times and the resulting data was analysed using content analysis.

Results: The older persons adapted to having their own needs and those of the other older persons met and to the staff routines which created a sense of security. At the same time, they longed for security in which they could trust themselves and create their own daily life. Further to have a sense of belonging and of being liked for created an internal, interpersonal and external security. This can be linked to an ontological security which means having a sense of confidence in the continuity of self-identity and order in events, a being in the world.

Conclusion: Person-centred instead of institution- centred care can provide the balance of power that allows the older person to obtain ontological security in which the staff's ability to create a relationship with the older persons becomes crucial.

Background

Shortcomings in elderly care have been reported in many parts of the world, including Sweden. However, national guidelines for elderly care have been introduced in Sweden, which contain core values and local guarantees of dignity. These highlight the need for dignity and well-being, and organising the older person’s daily life so that they perceive it as meaningful. Therefore, the aim of the present study was to describe older persons’ experience and knowledge about obstacles, opportunities and solutions to developing a meaningful daily life for those living in nursing homes.

Methods

This study combined the Participatory Appreciative Action Reflection (PAAR) and hermeneutic approaches. Twenty-five older persons participated and persons with dementia or cognitive impairments were included. Repeated interviews were carried out as reflective conversations, leaving 50 interviews in total, wherein the older persons provided their analyses and reflections on a meaningful daily life. Finally, an analysis of the data was completed based on a life-world hermeneutic approach.

Results

We identified five tentative interpretations that describe obstacles, opportunities and solutions for a meaningful daily life. Themes 2 and 4 outline obstacles for a meaningful daily life, and Themes 1, 3 and 5 describe opportunities and solutions for a meaningful daily life: (1) Having space to be yourself; (2) No space to be yourself; (3) Belonging and security; (4) A feeling of insecurity; and (5) Longing for something to happen. In the main interpretation, we found that the five tentative interpretations are related to Tuan’s concepts of space and place, where place can be described as security and stableness, and space as freedom and openness.

Conclusions

The reciprocal relationship is a solution for a meaningful daily life and occurs in the interaction between staff and older persons in nursing homes. It is the balance of power, and constitutes a place of shelter and a space of freedom for a meaningful daily life. The older person must have balance between shelter and freedom to have a meaningful daily life.

This interdisciplinary action research project has its background in the Swedish government’s introduction of national guidelines to address deficiencies in elderly care, wherein it gave each municipality the responsibility to formulate its own guidelines. The main purpose is how we successfully involved stakeholders to create and agree on core values and local guarantees of dignity with regard to elderly care. This paper focuses on the choices we made that led to the politicians adopting the guidelines, and we discuss the lessons learned. This project is based on a participatory and appreciative action and reflection approach. We worked with stakeholders, including managers, politicians, older persons, relatives, nurse assistants, nurses, occupational therapists, and organizations for retired persons (n ∼ 386) in elderly care in three phases from 2010 to 2013. Firstly, we cocreated practical knowledge via interviews, focus group discussions, and participated in nurse assistants’ work. Secondly, we trained managers who formulated preliminary core values and guarantees of dignity. Thirdly, we returned to the stakeholders for a critical review. We learned it is possible to manage a project and involve stakeholders in an action research project by having access to scheduled meetings, providing training to managers, and using appreciative intelligence and technical aids.

Background: In a larger action research project, guidelines were generated for how a meaningful daily life could be developed for older persons. In this study, we focused on the nurse assistants’ (NAs) perspectives, as their knowledge is essential for a well-functioning team and quality of care. The aim was to learn from NAs’ experiences and knowledge about how to develop a meaningful daily life for older persons in nursing homes and the meaning NAs ascribe to their work. Methods: The project is based on Participatory and Appreciative Action and Reflection. Data were generated through interviews,participating observations and informal conversations with 27 NAs working in nursing homes in Sweden, and a thematic analysis was used.

Result: NAs developed a meaningful daily life by sensing and finding the “right” way of being (Theme 1). They sense and read the older person in order to judge how the person was feeling (Theme 2). They adapt to the older person (Theme 3) and share their daily life (Theme 4). NAs use emotional involvement to develop a meaningful daily life for the older person and meaning in their own work (Theme 5), ultimately making each other’s daily lives meaningful.

Conclusion: It was obvious that NAs based the development of a meaningful daily life on different forms of knowledge: theoretical and practical knowledge, and practical wisdom, all of which are intertwined. These results could be used within the team to constitute a meaningful daily life for older persons in nursing homes.

PURPOSE: The purpose of this paper is to describe how first-line managers (FLMs) in home care (HC) reason about the opportunities and obstacles to lead the work according to the individual's needs and goals.

DESIGN/METHODOLOGY/APPROACH: In this participatory appreciative action reflection project, eight managers within one Swedish municipality were interviewed. The data were analysed using a thematic analysis.

FINDINGS: The results showed a polarization between two different systems that FLMs struggle to balance when attempting to lead HC that adapts to the needs and goals of individuals. One system was represented by the possibilities of a humane system, with human capital in the form of the individual, older persons and the co-workers in HC. The second system was represented by obstacles in the form of the economic needs of the organization in which the individual receiving HC often felt forgotten. In this system, the organization's needs and goals governed, with FLMs needing to adapt to the cost-effectiveness principle and keep a balanced budget. The managers had to balance an ethical conflict of values between the human value and needs-solidarity principles, with that of the cost-effectiveness principle.

ORIGINALITY/VALUE: The FLMs lack the opportunity to lead HC according to the needs and goals of the individuals receiving HC. There is a need for consensus and a value-based leadership model based on ethical principles such as the principles of human value and needs-solidarity to lead the HC according to the individual's needs and goals.

BACKGROUND: Today many older persons in ordinary housing receive home health care. It is stipulated that the care is to provide security; however, deficiencies in home health care are reported in many countries. It may be difficult to implement a sense of security among older persons receiving home health care in ordinary housing, especially during the evenings and nights, due to a lack of knowledge.

METHODS: This study is part of a larger project with a participatory appreciative action and reflection (PAAR) approach. We invited older persons, relatives, nurse assistants, registered nurses, and their managers to co-create knowledge with us on how conditions for a sense of security can be created during evenings and nights among older persons receiving home health care in ordinary housing. We performed thematic analysis of the data.

RESULTS: Five subthemes were developed that gave structure to two main themes. The first main theme, To confirm the self-image, has the following subthemes: To see the home as a reflection of the person's identity and To maintain self-determination. The second main theme, To create interaction in a sheltered place, has these subthemes: To undress the power, To create control and lifelines, and To create a good sleeping environment. The two themes interact and are each other's conditions. The person's self-image must be confirmed in order to create interaction in a sheltered place and through the interaction, the self-image is confirmed.

CONCLUSION: Conditions necessary for older persons to have a sense of security are living in a familiar environment, having habits and routines maintained, and having self-determination. Other conditions are equality, the prevention of falls, and an individualized sleeping environment. Older people's self-determination should be honored, and they should not being excluded from decision-making. We need to ask them if the conditions are sufficient and their sense of security is great enough to allow them to continue living in their ordinary housing.

Aims and Objectives: To explore nurse assistants' experiences and knowledge of how they create a meaningful daily life for older people receiving municipal home healthcare.

Design: A participatory appreciative action reflection approach.

Methods: Interviews, participant observations and informal conversations with 23 nurse assistants in municipal home healthcare generated the data. A thematic analysis was used.

Results: Two main themes were developed. The first main theme, building a reciprocal relationship, was structured by three subthemes: To strengthen the older person's self-esteem, to co-create care and to create equality. The second main theme, creating meaning, was structured by two subthemes: To create closeness and to receive appreciation. The two main themes are each other's prerequisite. Nursing assistants' building reciprocal relationships gives meaning; through the meaning, reciprocal relationships are achieved, and by that, meaningful daily lives for both the older people and the nurse assistants.

Conclusion: Nurse assistants built a reciprocal relationship both for the older people and for the nurse assistant. This contributes to create a meaningful daily life for the older people. The older person was the main character, and it seems that the nurse assistants apply person-centred care, which can represent a shared common vision that can be used in the encounter.

Introduction:  In Sweden new national guidelines for elderly care have been introduced containing core values and local guarantees of dignity that highlight the need for dignity, well-being and the organisation of the older person’s daily life so it is perceived as meaningful. Unit leaders play a crucial role in health care organisations when guidelines are to be implemented.

Aim: The aim was therefore to describe unit leaders’ experiences about what constitutes a meaningful daily life for older persons receiving municipal care and the opportunities and obstacles that may exist.

Method: Repeated interviews using reflective conversations with nine leaders were performed and analysed with qualitative content analysis.

Results: Unit leaders felt a shared vision regarding a meaningful life was needed. Daily routines and habits that promote independence, a feeling of community together with familiarity with the job, and that little extra from knowledgeable staff was important. The historical collective paradigm in elderly care needed to be abandoned in favour of one promoting more individualism. Fundamental was the courage to ask the older person what is important and dare to follow through “Give power to the older person to decide what care to be given”.

Conclusion: Organisational conditions affect unit leaders ability to succeed in the implementation of the work. Further studies are required regarding the nature of the support the unit leaders need to succeed in their work. 

Background: Shortcomings in elderly care have been reported in many parts of the world, including Sweden. National guidelines for elderly care have been introduced in Sweden, which contain core values and local guarantees of dignity. These highlight the need for dignity and well-being and organizing the older person’s daily life so that she/he perceives it as meaningful. Therefore, the aim of the present study was to explore opportunities, obstacles and search for solutions as described by the older person in order to create a meaningful daily life.

Methods: The design is based on the underpinning view of seeing the older persons as narrators of their own stories and interpreters of their own lives. Participatory Appreciative Action Reflection (PAAR) was used when collecting the data. Fifteen older persons participated, and repeated interviews were carried out as reflective conversations, in total 30 interviews. The older persons provided their analyses and reflections on what had been said regarding a meaningful daily life. Finally, an analysis of the data was done, based on interpretative description, and an inductive approach built on the key axioms of naturalistic inquiry.

Results: The older persons’ experiences and knowledge of opportunities, obstacles and solutions to a meaningful daily life can be summarized into four themes: (1) to live as usual, (2) collaboration with the staff, (3) the relationship carries everyday life, and (4) belonging to something. In the discussion, we choose to further develop these four themes by using Buber’s philosophy of dialogue.

Conclusions: An opportunity and a solution for meaningful daily life for the older person were seen in the relationship to oneself, to staff, to others, and the family. The reciprocal relationship, which occurred in the interaction between the staff and the older person, was the opportunity and solution for a meaningful daily life. It was the ongoing conversation between the older person and the staff who became "the glue" and formed the relationship. If the staff could support the older persons to maintain their habits and routines, these were solutions for creating a meaningful daily life. A meaningful daily life could be obtained in an I-Thou relation in a shared everyday life, where the relationship and the continuing dialogue becomes the power of balance. The relationship is also relevant for the staff and in line with Buber’s thoughts on how we are shaped by humans in the encounter with others.

In Sweden, older adults are living and being cared for under the responsibility of their respective community. Extensive reorganizations in the community led to management having different backgrounds, which may have caused uncertainty among community nurses, especially in decision-making processes. The aim was to understand how 10 nurses, 10 doctors and 10 home care assistants as leaders for the nurses conceptualized the decision-making processes of community nurses, when referring older persons to Emergency Departments, and whether perceptual differences and/or similarities exist. Narrative interviews and content analysis were performed. The managers had differing views, but all felt there was a need to feel secure in order to trust professional decisions as being correct, thus avoiding inappropriate referrals. Management could see nursesexposed position, but had varying solutions. This might lead to different messages being given regarding what is important and might explain why the nurses reported that the managers did not understand them.

AIMS: To describe leaders' perspectives on what is important to create a meaningful daily life for older persons receiving municipal elderly care.

DESIGN: This study combined the Participatory Appreciative Action Reflection approach and qualitative methods.

METHODS: Focus Group Discussions were performed with eighty leaders that was analysed with qualitative content analysis.

RESULTS: One overall theme emerged "We have to turn a transatlantic liner". The leaders proposed a need to change from an institutional care to a more person-centered care approach on all levels of the healthcare system. This meant that everyone in the organization needed to think outside the box and find new ways to provide care to older persons. They needed to hire the right persons with the right values and knowledge. The leaders would need to provide for and support staff empowerment. There was also a need to see the older person and their relatives as co-participants. No Patient or Public Contribution.

Background: A valid and reliable tool is crucial for municipal registered nurses (RNs) to make quick decisions in older adults who show rapid signs of health deterioration. The aim of this study was to investigate the psychometric properties of the Decision Support System (DSS) among older adults in the municipal healthcare system.

Methods: Firstly, we utilized the Rasch dichotomous model to analyze the DSS assessments (n=281) that were collected from municipal RNs working with older adults in the municipal healthcare system. We examined the properties of the DSS in terms of its unidimensionality, item fit, and separation indices. Secondly, to investigate inter-rater agreement in using the DSS, four experienced municipal RNs used the DSS to assess 60 health deterioration scenarios presented by one human patient simulators. The 60 DSS assessments were then analyzed using the ICC (2,1), percentage agreement, and Cohen kappa statistics.

Results: The sample of older adults had a mean age of 82.8 (SD 11.7). The DSS met the criteria for unidimensionality, although two items did not meet the item fit statistics when all the DSS items were analyzed together. The person separation index was 0.47, indicating a limited level of separation among the sample. The item separation index was 11.43, suggesting that the DSS has good ability to discriminate between and separate the items. At the overall DSS level, inter-rater agreements were good according to the ICC. At the individual DSS item level, the percentage agreements were 75% or above, while the Cohen kappa statistics ranged from 0.46 to 1.00.

Conclusions: The Rasch analysis revealed that the psychometric properties of the instrument were acceptable, although further research with a larger sample size and more items is needed. The DSS has the potential to assist municipal RNs in making clinical decisions regarding health deterioration in older adults, thereby avoiding unnecessary emergency admistion and helping.

The Swedish government implemented a reform, the Adel reform, in the care of older citizens in 1992, so that the communities where older people live became responsible for their care and housing. Nurses were appointed to make sure that older people were given accurate care and to act as supervisors for nurses' aides. In this study, 10 Registered Nurses from community home care services and four consultant head physicians in primary care were interviewed in order to illuminate what they thought influenced nurses' decisions to refer patients for emergency treatment and what support they requested to facilitate the decision. Content analysis showed the necessity of feeling secure in one's role as a community nurse. The categories that developed were: own competence, knowledge about the patient and a supportive working environment. The main theme was To feel safe in one's role - a basis for decision-making. High demands were put on the nurses' competence and their burden of responsibility became too great. This influenced decision-making negatively, if nurses felt that they were lacking in their own personal competence. Training in documentation for the nurses was required, as well as the need for organizations to provide staff with sufficient time for accurate documentation. A greater input of nursing and medical care was required to make it possible for patients to be cared for at home if they so wished. Respondents described considerable deficiencies in their working environment and in co-workers' competence, and nurses' professional roles within the community were not made clear. If these problems were remedied, this would improve working conditions, increase understanding, and reduce feelings of uncertainty among decision-makers.

The aim of this study was to describe, through observations and interviews with patients >/=75 years old and the relatives who accompanied them to the hospital, the conditions at the emergency department (ED) and the events that took place during the waiting period. Twenty older patients were studied, together with their relatives. A modification of a comparative design, the interpretative method 'grounded theory', was utilized. Open, nonparticipant observations were carried out; from the time patients were admitted until the time they were discharged. Patients were observed through all stages, for example, in the reception area, in the examination room, and in the X-ray department. The observations were supplemented with field notes and interviews with the older patients as they left the ED. The selective coding developed into six core-variables that were the focus of the material. These were: unpleasant waiting, unnecessary waiting, lack of good routines during the waiting stage, suffering during the waiting stage, bad feelings during the waiting stage and nursing care during the waiting stage. The way, in which nursing care was carried out, which in this context is discussed in terms of praxis and poieses, appeared to be of major importance for the older peoples' experiences when visiting the ED.

AIM: The aim of the study was to use the experiences of emergency nurses to illuminate what constitutes good nursing care for patients 75 years or older transferred to emergency departments.

BACKGROUND: Emergency departments have a medical technical character and the number of visits there increases dramatically as people age. Older patients require increased healthcare services in terms of nursing care, interventions and hospitalizations due to an increased complexity of their problems. For these reasons it is important to study what good nursing care of the older patients consists of at an emergency department from the emergency nurses' point of view.

METHOD: Ten emergency nurses from a university hospital emergency department in Sweden were interviewed. A thematic content analysis was performed.

RESULTS: The study showed that it was necessary to be knowledgeable, to be understanding of the older patients' situation and to take responsibility for them in order to be able to provide good nursing care. The emergency nurses shifted focus from describing the central aspect of good nursing care to describing what hinders the provision of it. Their experience was that prioritizing medical procedures, everyday tasks and routines threatens good nursing care of older patients in emergency departments. The emergency nurses held that the older patient is often sent to an emergency department where the level of care is not appropriate to their needs.

CONCLUSIONS: The result can be seen as a challenge for the organization and the nurses in the future; to prioritize differently, thereby maintaining a balance between good nursing and medical/technical tasks when treating older patients.

RELEVANCE TO CLINICAL PRACTICE: The present day healthcare system is not organized to appropriately meet the needs of the older patients. Nurses themselves hold they can better serve the older patient. By sharing their experiences, both can be accomplished.

BACKGROUND AND AIM: Due to reported shortcomings in elderly care in Sweden, the government has introduced national guidelines to establish core values and guarantees of dignity. With a bottom-up perspective, core values and local guarantees of dignity were developed using an participatory and appreciative action and reflection (PAAR) approach and implemented in municipal elderly care. The aim of this study was to evaluate the core values and local guarantees of dignity applied by the municipal healthcare staff caring for older persons.

METHOD AND RESULTS: A cross-sectional descriptive design study using a questionnaire was conducted one year after the implementation of core values and local guarantees of dignity in municipal elderly care. In total, 608 caregivers answered the questionnaire. The results show that the caregivers strived to apply the core values and local guarantees of dignity, but experienced obstacles from the organisation. Proposals were given to facilitate further application of the core values.

The aim of the study was to describe the basis on which municipal care registered nurses (RN) make decisions and their experiences when referring older persons from nursing homes to emergency departments (EDs). RNs in the community are to ensure that older adults receive good care quality in nursing home. This study used a descriptive design with a qualitative content analysis. The analysis of the data from the 13 interviews revealed one theme “Shared responsibilities in the best interests of the older person reduce feelings of insufficiency”. The content was formulated, which revealed the RNs’ feelings, reasoning and factors influencing them and their actions in the decision-making situation, before the patients were referred to an emergency department. Complex illnesses, non-adapted organizations, considerations about what was good and right in order to meet the older person’s needs, taking account of her/his life-world, health, well-being and best interests were reported. Co-worker competencies and open dialogues in the “inner circle” were crucial for the nurses’ confidence in the decision. Hesitation to refer was associated with previous negative reactions from ED professionals. The RN sometimes express that they lacked medical knowledge and were uncertain how to judge the acute illness or changes. Access to the “outer circle”, i.e. physicians and hospital colleagues, was necessary to counteract feelings of insecurity about referrals. When difficult decisions have to be made, not only medical facts but also relationships are of importance. To strengthen the RNs’ and staff members’ competence by means of education seems to be important for avoiding unnecessary referrals. Guidelines and work routine need to be more transparent and referrals due to the lack of resources are not only wasteful but can worsen the older persons’ health.