To Örebro University

Postoperativ smärta är relaterad till vävnadsskadan som uppstår i samband med operation. Denna smärta kan många gånger vara svår att lindra optimalt med olika farmaka och underbehandlas i stor utsträckning. Syftet med denna litteraturstudie var att beskriva olika icke farmakologiska metoder som kan lindra postoperativ smärta hos vuxna. Metoden som användes bestod av en litteraturstudie där data samlades in genom systematiska databassökningar samt manuella sökningar. De icke farmakologiska metoder som framkom var specifik preoperativ information, avslappning, vägledd visualisering, akupunktur, massage, musik och vibrationsterapi. Metoderna kunde utföras av både sjuksköterskor och annan sjukvårdspersonal. Det framkom i flera artiklar att patienterna även kunde använda några av dessa metoder i egenvårdande syfte. De icke farmakologiska metoderna som framkom i litteraturstudien visade sig kunna lindra postoperativ smärta.

AIM:

To review systematically research conducted during the past five years focusing on the relatives' situation and needs in end-of-life care.

BACKGROUND AND AIM:

That relatives make a large contribution in the care of the dying is well-known. In this situation, relatives often have to solve many new practical problems in the care as well as dealing with the sorrow of both themselves and the dying person. In recent years, palliative care has been developed in many countries and many new studies have been carried out.

METHODS:

A systematic search of the literature was performed in the CINAHL and Medline databases. Of the 94 papers analysed, there were 59 qualitative and 35 quantitative studies with differing designs. The studies were carried out in 11 countries and were published in 34 different journals.

RESULTS:

The results were categorized in two main themes with several subthemes: (1) being a close relative--the situation: (i) exposed position--new responsibility, (ii) balance between burden and capacity and (iii) positive values; (2) being a close relative--needs: (i) good patient care, (ii) being present, (iii) knowing and communicating and (iv) support from and trusting relationship with the professional. The relative's feelings of security and trust in the professional were found to be of great importance.

CONCLUSION:

More than twice as many studies had a descriptive/explorative design, which is of importance in the assessment of evidence. However, different studies complement one another and in summary, it can be said that analytic evidence is unequivocal: good patient care, communication, information and the attitude of the professional are of decisive importance regarding relatives' situation. These results are also in accord with earlier review studies.

RELEVANCE TO CLINICAL PRACTICE:

Staff members have a great deal of responsibility for assuring that the patient feels as good as possible, facilitating relatives' involvement based on the family's wishes and limiting the stress and difficulties experienced by the family. The results showed that the relative's satisfaction could depend on the attitude of the professional as well as on good communication, good listening and good information. This can also be viewed as a prerequisite for the professional to get to know the family and to provide 'care in the light'.

This article summarises a number of studies in palliative care with the following primary aims; to describe and obtain increased understanding for the relatives' situation; to analyse the involvement of the relative; to analyse obstacles to and possibilities for the relatives' involvement; and to develop a theoretical framework of understanding concerning their involvement. The main results from the summarised studies show that the relatives' involvement in the patients' care could be classified into three main categories: "to know", "to be" and "to do". The studies show that the relatives' involvement can be described as either involvement in the light or involvement in the dark. Involvement in the light and in the dark illustrates the relatives' understanding of the situation, their possibilities for involvement, ad the attitude of the staff towards the relatives. A pattern which was observed was that those relatives who were involved in the light described having been met with respect, openness, sincerity, confirmation, and connection, while the opposite was the case for those who were involved in the dark. A surprising result was that the time between the patient?s cancer diagnosis and death was three months or less for 49% of 67 patients. In those cases where the course of illness was short, there was no time to lose and it was important that caring delays were avoided. Factors that promoted involvement in the light were professional care based on humanistic values, a stronger sense of coherence of relatives, an appropriate course of illness, and other available resources such as other relatives and one's own health. The result from the studies were summarised in five assumptions which together form a theoretical framework of understanding for the involvement of relatives.

The current study is based on an earlier article in which relatives' involvement in care was described as involvement in the light or involvement in the dark. Involvement in the light was characterized as the relative being well informed and experiencing a meaningful involvement. The relatives involved in the dark felt uninformed, that they were groping around in the dark when they tried to support the patient. The present study analyzed further the meaning of involvement in the light and involvement in the dark, and investigated whether two different care cultures, the relationship with the staff, and a rapid course of illness influence the involvement of relatives. Relatives of 52 patients who died, 30 at a surgical department and 22 in a hospice ward, were interviewed after the patients' deaths. All the relatives of the patients in the hospice ward and 13 of those in the surgical department were judged to be involved in the light. Of the relatives judged to be involved in the dark, 12 either had a sick relative with a rapid course of illness or felt that the sick relative had died unexpectedly. A pattern was clearly observed: The relatives involved in the light described being met with respect, openness, sincerity, confirmation, and connection, whereas the opposite was experienced by those involved in the dark.

BACKGROUND:

The present study is based on four earlier studies in which the authors classified the relative's involvement in palliative care into different categories and described the involvement as "involvement in the light" or "involvement in the dark".

AIM:

The aim of the study was to develop a theoretical framework concerning the involvement of relatives based on an in-depth analysis of the results of the four earlier studies.

METHOD:

Walker & Avant's (1995) strategies for theory construction were used for development of the framework. A number of different concepts, assumptions and statements about relatives' involvement were penetrated in an in-depth analysis.

RESULTS:

From the concepts two theoretical "blocks" of the relatives' involvement were developed and these constitute the foundation for the framework. One is based on concrete descriptions of the concepts "to know", "to be" and "to do". The other describes how the concepts of "involvement in the light" and "involvement in the dark" differ. Factors that promoted involvement in the light were professional care based on humanistic values, a stronger sense of coherence on the part of relatives, an appropriate illness trajectory, and other available resources. The opposite was the case for those who were involved in the dark. Five assumptions successively developed which together form the theoretical framework.

CONCLUSIONS:

An important conclusion that can be of importance in palliative care is that the manner in which the staff act toward the patient and relatives influence relatives' possibilities for involvement, patients' possibilities for an appropriate death, and the possibilities the staff have to give good care.

A prerequisite for the staff to be able to guide relatives through the dying trajectory is that the staff members know what the relative wants and can do. The aim of this study was threefold: (a) to identify and categorize family members' involvement in the care of a dying relative, (b) to develop a theoretical understanding of their involvement, and (c) to discuss the congruence or incongruence between the empirical results and key concepts in Swanson's and Watson's theories of caring. The results show that the relatives' involvement could be classified into three categories: to know, to be, and to do. Good correspondence was found between these three categories and key concepts in Swanson's and Watson's theories of caring.

The aim of this prospective study was to increase existing knowledge about the involvement of relatives in care of the dying and to shed light on the relatives' sense of coherence. Six relatives were followed via qualitative interviews during the patients' final period of life and after their deaths. The patients died in different forms of care: surgical department, nursing home, inpatient hospice ward, and at home. What the relatives had in common was that they had, in different ways, followed the patient from the first symptoms, through different forms of care, up until death. Some participated very actively in the care. Relatives' involvement in care can be described as involvement in the light or involvement in the dark. Involvement in the light is based on a trusting relationship between the family and the staff. Involvement in the dark is based on insufficient interplay and collaboration, in which the relatives are not seen or acknowledged by the staff, but instead must grope around in the dark when they try to support the patient. Rapid course of illness can be a risk factor for involvement in the dark. It seems that the relatives' sense of coherence was an important factor enabling them to be involved in the light. Humanistic care can constitute a buffer, thereby increasing the possibilities for relatives to be involved in the light.

A majority of people die in acute hospital care, in a culture of quickness primary aimed at curing. There are indications that hospice care in various forms will spread during the present decade in Sweden. The hospice philosophy contributes to a culture of slowness, where the patient is not only allowed but is encouraged to live at his own pace. As a first step in establishing for whom hospice inpatient care is the best alternative, patient flow to a newly started hospice ward was studied. All patients (n = 1464) who died at the Medical Centre Hospital with a primary diagnosis of cancer during the period of study were compared regarding place of death, diagnosis, gender, age and length of the last period of care. The year before the ward was established, 82% of patients died in acute hospital care compared with 59% during the hospice ward's third year of operation. A total of 315 patients (22%) died in the hospice ward during the study period. The percentage of these patients over the age of 80 was significantly higher (p = 0.0001), and they also had a longer continuous final period of care. More women (57%) than men (43%) were cared for at the hospice ward. The hospice ward has in this way influenced the pattern of care in the hospital.

The aim of this study has been to retrospectively examine the illness trajectory for a consecutive group of sixty-seven patients with cancer who died at a surgical department or were referred from there to an inpatient hospice ward where they died. Relatives of fifty-two patients were interviewed after the patient's death and all sixty-seven medical records were studied. The data was analyzed with support of Glaser and Strauss' concept of a dying trajectory. A surprising result was that as many as forty-four patients had a short trajectory, and nineteen of these had one month or less between diagnosis and death. Patients at surgical wards followed a faster trajectory and were in a somewhat poorer state of health when compared to patients at the inpatient hospice ward. In the case of trajectories within three months, there is no time to lose, and it is important that caring delay are avoided.

In this study the aim was to explore and describe next of kin's feelings of guilt and shame in end-of-life care via secondary analysis of 47 qualitative interviews. In the analysis categories and subcategories emerged which conveyed how the next of kin experienced guilt; not having done or talked enough, being absent at important events or making errors of judgement. Categories conveying feelings of shame were situations where the next of kin felt inferior, was ashamed on behalf of the dying person and when family conflicts became apparent. Receiving help and support in order to make the remaining period as pleasant as possible can facilitate the next of kin's sense of having fulfilled their duties and responsibilities and therein reduce feelings of guilt and shame. It is apparent that these feelings should be taken into account and the next of kin should receive support to increase their well-being during the remaining time in end-of-life care and the grieving period.

Syftet med denna studie är att beskriva familjens och sjuksköterskans upplevelser vid palliativ omvårdnad av barn. En systematisk litteraturstudie har gjorts och vetenskapliga artiklar har sökts fram, vilka ligger till grund för denna studie. Resultatet visar att familjerna upplevde att tydlig information samt stöd både under och efter den palliativa omvårdnaden var viktig. Det framkommer även i resultatet att sjuksköterskorna upplevde att stöd var en central del av den palliativa omvårdnaden. En del av sjuksköterskorna upplevde att de hade för lite kunskap och erfarenhet för att kunna bemöta familjerna på ett professionellt sätt. Ytterligare forskning bör bedrivas för att öka sjuksköterskans kunskaper och därmed underlätta familjernas situation.

Bröstcancer utgör den främsta cancerdiagnosen hos kvinnor i Sverige. Stor

betydelse för uppkomst av bröstcancer har de kvinnliga könshormonerna. Behandling

av bröstcancer sker genom operation, cytostatika, antihormoner och/eller strålning.

Behandlingen kan leda till fysisk och psykisk påverkan. Syftet med denna

litteraturstudie är att beskriva hur yngre kvinnors livssituation påverkas av

bröstcancer samt hur sjuksköterskan kan möta dessa kvinnors behov. Artiklarna till

litteraturstudien har sökts fram i databaserna Cinahl, Medline och PsycInfo samt

genom manuell sökning och resultatet kom att omfatta 16 artiklar. Dessa artiklar har

värderats, bearbetats, analyserats och sedan sammanställts. Resultatet visar att en

cancerdiagnos innebär många olika känslor för de yngre kvinnorna, vilket får dem att

fungera sämre i det dagliga livet. Förhållandet till familjen förändras och sjukdomen

får en stor inverkan på kvinnans yrkesliv och ekonomi. De stora områden som

påverkas i samband med bröstcancer hos yngre kvinnor är infertilitet, för tidig

menopaus, förändrad kroppsuppfattning samt påverkan av kvinnans sexualitet.

Sjuksköterskan har en viktig roll i vården av yngre kvinnor med bröstcancer och kan

påverka kvinnan både positivt och negativt. Det framkommer också att behovet av

relevant information för kvinnans ålder är stort. När yngre kvinnor drabbas av

bröstcancer påverkar det hennes liv på många sätt. Områdena som berörs skiljer sig

många gånger från andra grupper med bröstcancer. Detta måste tas hänsyn till inom

sjukvården, för att ge optimal vård.

The aim was to describe different processes in what is termed the “educational career” of hard-of-hearing students. The data comprises narratives from 30 hard-of-hearing former students representing four groups: students from a special school who continued to university education or to employment; students from ordinary schools who continued to university education or to employment. The results indicate that support within the educational experience is of great importance and the social support provided by parents is of crucial importance for a student's educational trajectory or career. This support, in combination with an adjusted school environment, seems to greatly diminish the importance of the hearing impairment. The conclusion is that hard-of-hearing students should not necessarily choose a special school just because of the impairment itself. When the needs of these students are met, there seem to be more accentuated mechanisms in ordinary educational settings than in special schools that promote post-secondary education.

Background Self-rated participation is a clinically relevant intervention outcome for people with mild intellectual disability. The aim of this systematic review was to analyse empirical studies that explored relationships between either environmental factors or individual characteristics and aspects of participation in young adults with mild intellectual disability. Method Four databases were used, 756 abstracts examined and 24 studies were evaluated in-depth. Results Four aspects of participation were found: involvement, perceptions of self, self-determination and psychological well-being. Reported environmental factors were: social support, choice opportunity, living conditions, school, work and leisure, attitudes, physical availability and society. Reported individual characteristics were adaptive and social skills. Conclusions There is a relative lack of studies of factors influencing self-rated participation and existing studies are difficult to compare because of disparity regarding approaches, conceptual frameworks, etc. For adequate interventions, it seems important to study how profiles of participation are influenced by different patterns of environmental factors and individual characteristics.

En nationell interaktiv webbplats- www.kuling.nu arbetades 2003 fram på Psykosvårdens utrednings-och behandlingsenhet, Karlakliniken. Webbplatsen riktar sig till barn och ungdomar som har en förälder med psykisk sjukdom och är en del av det anhörigstöd som erbjuds på enheten. Denna studie görs som en uppföljning av kuling.nu där syftet är att beskriva den interaktiva webbplatsen kuling.nu med avseende på innehållet i besökarnas inlägg på diskussionsforumet samt användningen av webbplatsen. Huvudinläggen på kuling.nus diskussionsforum har analyserats med hjälp av kvalitativ innehållsanalys. Analysen gav sex teman som speglar innehållet i inläggen: ensamhet; att bära ansvar; känsloupplevelsen; betydelsen för den egna personen; sökande efter svar och förmedling av stöd. En mörk bild av situationen för barn till en förälder med psykisk sjukdom förmedlas i inläggen och en stor ensamhet med förälderns sjukdom. Den tillskrivs ansenlig betydelse för den egna personen och ger svårigheter som behöver bearbetas. Uppföljningen visar att kuling.nus syfte att ge stöd till barnen uppfylls genom det stöd skribenterna ger varandra i sina inlägg på diskussionsforumet och den informationen om psykisk sjukdom som finns på webbplatsen.

Under åren 1990-1993 utarbetade Förenta Nationerna [FN] regler om jämlikhet och delaktighet för personer med funktionsnedsättning. Arbetet resulterade i 22 standardregler som antogs vid generalförsamlingen år 1993.

Som ett led i detta formulerade regeringen propositionen ”Från patient till medborgare - en nationell handlingsplan för handikappolitiken” vilken överlämnades och antogs av riksdagen år 2000 och berör bland annat tillgänglighet. Tillgänglighet är relationen mellan person och miljö och den påverkas av faktorer hos dessa två komponenter. Enligt arbetsterapeutiska teorier påverkar miljön en persons aktivitet genom att miljön kan ha en möjliggörande eller hindrande effekt på utförandet av en aktivitet.

Syftet med denna studie är att kartlägga den fysiska miljön och tillgängligheten för rullstolsburna i biblioteksmiljö. Åtta bibliotek som är öppna för allmänheten s.k. folkbibliotek inkluderades i studien. Data samlades in genom en observation utifrån en checklista baserad på instrumentet ”Housing Enabler” samt Handikappinstitutets bok ”Bygg ikapp handikapp”. Resultatet visar att det finns faktorer i miljön som kan påverka tillgängligheten på samtliga bibliotek. Felplacerade automatiska dörröppnare, otillräckliga manöverutrymmen, hyllor och hyllplanens placering samt olämplig utformning av handikapptoaletterna är några miljöhinder som identifierades och som kan ge upphov till tillgänglighetsproblem för personer som förflyttar sig med rullstol. Ett stort antal miljöhinder som observerades kan utifrån Boverkets föreskrifter klassas som enkelt avhjälpta hinder och bör undanröjas.

Abstract

Our study illustrates how disabled high school students, their assistant and physical education teacher experience inclusion within the physical education. A total of seven interviews have been done to show their experiences. The questions we have chosen are: How do the student, assistant and physical education teacher experience their relationships? How do the student, assistant and physical education teacher experience the physical education? How do the student, assistant and physical education teacher experience inclusion of the student in the physical education?

To illustrate their experiences a total of seven interviews have been done. They were carried out at the students schools, in the environment they are familiar to. The interviews were taped to later be transcribed and the material was analysed in four steps.

In this study we refer inclusion to participate in an entirety. It is also about to considerate the conditions of every individual and to create the possibilities for the individual from this. To work towards inclusion means that everybody involved has to work towards the same goal to reach the best result.

From this study we have seen that the disabled students are included in the physical education, but it can appear in different ways. They participate as much as they can and some exercises are adjusted to their needs. Another aspect to have in mind is that the students want to participate in the physical education. We have only studied two cases and can therefore not make a generalization of disabled students in general, we can just say how it is for the high school students we have interviewed.

Keywords: Inclusion, children, disabilities, physical activity, education

AIM: The aim of this paper is to focus on the abilities needed to create the caring relation in palliative home care and to find ways to describe these abilities and skills from an esthetic perspective.

BACKGROUND: Nurses in Palliative home care have to create a functioning relationship between themselves the patient and the patient's next of kin, this puts special demands on the nurse. A number of abilities, such as creativity, intuition, empathy and self-knowledge are mentioned in literature related to the caring relation. Many nursing theorists have referred to the art and esthetic of nursing when trying to describe these abilities.

METHODS: Data were collected using semi-structured interviews with eight expert nurses in palliative home care. The transcribed interviews were analysed using qualitative content analyses.

FINDINGS: Three main categories where found: The will to do good, Knowledge and Perceptiveness. Subcategories that can be seen as abilities where found in the main categories knowledge and perceptiveness.

CONCLUSIONS: The main categories can be seen as expressions for abilities, personal qualities and skills needed to create the caring relation in palliative home care. We found interesting connections between the three main categories and the concepts of esthetics, ethics and science. We also found that nurses develop in a way, i.e. similar to an artist.

RELEVANCE TO CLINICAL PRACTICE: The concepts brought forward in this paper could be used in clinical supervision and education as well as in clinical practice. If nurses think about the three aspects: Knowledge, the will to do good and perceptiveness, the chance for a positive relation between the nurse and the patient, and the patient's next of kin might increase. One could speculate that perceptiveness is a vital ability in order to achieve the expert level of nursing and that this perspective should be taken in consideration when recruiting nurses and in curriculum development.

Syftet med uppsatsen var att undersöka hur bemötandet och tillgängligheten i den fysiska miljön på caféer upplevs av rullstolsburna cafébesökare och caféägare i Örebro 2006, samt undersöka vad respektive grupp vet om handlingsplanen "från patient till medborgare".

Datainsamlingen gjordes genom intervjuer med tre rullstolsburna cafébesökare samt sex caféägare som delades upp i två grupper, grupp 1 med fysiska hinder vid entrén och grupp 2 utan hinder vid entrén.

Resultatet av studien visade att de rullstolsburna cafébesökarna tyckte oftast att cafémiljön ger ett gott bemötande men att utbudet av fysiskt tillgängliga caféer var dåligt. Samtliga caféägare upplevde att de gav ett gott bemötande men upplevelsen av den fysiska tillgängligheten varierade. Samtliga rullstolsburna cafébesökare var insatta i handlingsplanen "från patient till medborgare", ingen av caféägarna var insatta i den.

Different methodological tendencies within the field of disability research are described, and the reductionism implicit in the historically dominant models is critiqued. The advantages of critical realism over rival metatheoretical positions, including empiricism, social constructionism, neo-Kantianism and hermeneutics, is shown, demonstrating in particular what is called the “double-inclusiveness” of critical realism. A non-reductionist schema for explanation in disability research is established, and the article argues that the phenomenon of disability has the character of a “necessarily laminated system”. The fruitfulness of this approach is then illustrated with an example drawn from the field, and the case for critical realism as an ex ante explicit metatheory and methodology for disability research is further developed. The conclusion reconsiders the nature of metatheory and its role in research.

Aims and objectives. The aim of this study was to describe how care team members caring for patients with advanced cancer describe how they handle difficult situations in daily care. In this paper 'difficult situations' refers to those situations team members themselves describe as difficult. Background. Serious illness and impending death involve great changes in a person's life. The care of patients with advanced cancer is complex and many different factors influence each care situation. This places demands on the way care team members handle problems and difficulties in daily care. Design. Qualitative descriptive study. Methods. The study is based on 16 focus group discussions with care team members who were caring for patients with advanced cancer at three different care units in two Swedish cities. The focus group discussions included 77 participants. The procedure for data analysis was inspired by the phenomenological method. Findings. The results show that care team members handled difficult situations by balancing between being close and distancing themselves. In most situations their choice of strategy seemed spontaneous rather than being a conscious decision, although it was sometimes described as a more conscious approach. Variations of closeness and distance that were identified were Identity, Meaning, Limit-setting and touching, Prioritization, the Team and the Organization. These could also be seen as tools that could facilitate or impede the use of closeness and distance. Conclusions. The results show that care team members have a need to reflect over daily care and to become aware of what governs different care actions. Relevance to clinical practice. If the experienced difficult situation is not handled in a way that is beneficial to the care team member, patient and relatives, it is assumed that this can result in stress, burnout and, above all, non-optimal care.

In Stockholm, Sweden, women are invited to a cost-free population-based cervical cancer screening programme (PCCSP) at regular intervals. Despite this, many women choose not to attend screening at all or to take opportunistic tests instead. This study explores bow women who actively declined participation in the PCCSP reasoned about their choice. Qualitative telephone interviews and fax, messages from women who actively declined participation in the PCCSP were analysed inductively. The manner in which women defined and conceptualized distinctions between, and the roles and responsibilities of, both private and public spheres were found to be central in explanations of decision making. Factors related to women's decisions not to participate in screening at all include a lack of confidence in the benefits of screening, previous negative health care and preventive experiences, a belief in one's own ability to discern health changes or a belief that one was not at risk for cervical cancer, as well as a number of unconventional standpoints on social and political issues. Women who chose not to participate in the organized PCCSP, but who did use private opportunistic screening, generally motivated this with direct or indirect criticism of the screening programme itself. Not only was the examination itself sensitive but also all facets of the PCCSP, from invitation letter on, were found to influence women's decisions. Using Jepson et A's ethical framework to peruse the evidence-base underlying women's 'informed decision-making' about CCS is suggested to be more constructive than discussing potential participants' knowledge versus lack of knowledge.

OBJECTIVES:

In the light microscope compare the amount of bone saucerization for non-threaded cylindrical and threaded implant designs in retrieved samples from patients.

MATERIAL AND METHOD:

Consecutively received retrieved oral implants from 117 patients, whereof 85 non-threaded cylindrical and 85 Brånemark implants, have been included in the study. For 75 non-threaded cylindrical and 46 Brånemark implants was the entire implant length available for calculation. Undecalcified ground sections were investigated in the light microscope with calculation of percentage of implant length coronal to the first bone-implant contact and percentage of bone to implant contact.

RESULTS:

Mean value for implant length coronal to first bone-implant contact was 65%, standard error of the mean (SEM) 3 (range 0-100%), for non-threaded cylindrical implants and 43%, SEM 6 (range 0-100%) for Brånemark implants. Mean values of bone contact along the entire implant length was 23%, SEM 2 (range 0-65%), for the non-threaded cylindrical implants and 33%, SEM 5 (range 0-93%) for the Brånemark implants.

CONCLUSION:

Within the limitations of this retrospective, retrieval study non-threaded cylindrical implants demonstrated a greater bone saucerization when evaluated in the light microscope.

A chronic disorder affects all members of the family in various ways. The aim of this study is to elucidate the next of kin's (N= 36) experiences when an adult family member has muscular dystrophy. The relationships were partner (36%, n= 14), parent (18%, n= 7), child (21%, n= 8), sibling (15%, n= 6), and other relative (3%, n= 1). Latent content analysis is employed and involves an interpretation of the interviewtext. The results showthe meaning of being close to a person with muscular dystrophy through the themes that emerged: exposure of the family; the span between obligation and love; being vigilant, protective, and supportive; and striving for an ordinary life. This study reveals a need for healthcare staff to understand the next of kin's narrated meaning of changes when a family member has a progressive disease.

En riskfaktor för psykisk ohälsa bland barn och ungdomar är alkoholmissbruk i familjen.

Barnen och ungdomarna kan indelas i tre grupper, de som mår bra, de som befinner sig i en gråzon, och de som far illa. I denna rapport fokuseras på de barn som far illa. I Sverige finns ca 200 000 barn som lever med minst en förälder som missbrukar alkohol. Studier från andra länder visar också höga siffror och det innebär att det finns två till åtta barn i varje grupp om 25 barn som växer upp i en familj med dessa problem. En amerikansk studie har visat att det är nästan vart tredje barn som är barn till alkoholiserade föräldrar. Livet i en alkoholistfamilj kan vara kaotiskt och oförutsägbart, men också mycket varierat mellan olika familjer.

Syftet med denna systematiska kunskapsöversikt är att beskriva vilken kunskap som idag finns om psykisk hälsa och ohälsa hos barn med en alkoholiserad förälder alternativt båda föräldrarna samt vilka risker barnen utsätts för. I översikten kommer även vilket stöd och skydd dessa barn behöver och kan få i Sverige idag att presenteras. Kunskapsöversikten kommer dessutom att granska vilka interventioner som utvärderats och presenterats i svensk och internationell forskning Systematisk litteratursökning har gjorts i flera databaser för att hitta vetenskapliga publikationer inom området och en genomgång av samtliga avhandlingar i socialt arbete som skrivits vid fem universitet i Sverige har gjorts. Även andra vetenskapliga rapporter finns med i kunskapsgenomgången. Dessa har hittats mera slumpmässigt vid genomgång av referenslistor, sökning på olika myndigheters databaser, tips från andra forskare m.m.I resultatet presenteras den utsatthet barn till alkoholmissbrukare har ökad risk för. Det kan vara emotionella svårigheter, anpassnings- och beteendeproblem, skolproblem med svårigheter i kamratkontakter och kognitiva problem, samt risk för en ökad alkoholkonsumtion. De skyddsfaktorer som redovisas är faktorer inom barnet själv, stöd till föräldrar och därigenom ett indirekt stöd till barnen, direkt stöd till barnen, t.ex. i form av signifikanta vuxna, samt kritiska händelser som kan fungera skyddande. I Sverige stöder regeringen gruppstödsverksamheter för barn till alkoholiserade föräldrar. I den aktuella kunskapsgenomgången redovisas forskning på interventioner för barn till alkoholiserade föräldrar. Det finns få rapporterade interventioner som också är utvärderade. Trots kritiken mot att så få utvärderade interventionsstudier gjorts, förordas fortsatt gruppstödsverksamhet för barn till alkoholiserade föräldrar samt att individuella och familjebaserade interventionsprogramn utvecklas och utvärderas.

There are few studies on substance use, mental symptoms and school problems in adolescents with multi-disabilities. This survey, “Life and health-young 2005”, included all children in mainstream schools class 9 in the county of Örebro, Sweden. Children attending special schools for deaf/hard-of-hearing and multi-disabled children were not included. There were 56 (1.9%) hard-of-hearing students with some other disability, 93 (3.1%) ‘just hard-of-hearing’ students, 282 (9.7%) students with some other disability than hearing impairment and 2488 (85.2%) without a disability. Hard-of-hearing/other disability group of students reported considerably higher scores on mental symptoms, substance use and school problems than the others. A logistic regression analysis showed that mental symptoms explained 17% of the variance, alcohol and drugs 15% and school problems 9%. The final model explained 24% and included use of illegal drugs (OR 8.3), often irritated (OR 4.2), feeling bad (OR 3.2) and bullied (OR 2.2). In the hard-of-hearing/other disability group 43% reported at least 2 of these symptoms and in the other groups 17%, 18% and 8%, respectively. The combination of hearing impairment and other disabilities increases the risk for mental symptoms, substance use and school problems. This group of students in mainstream schools ought to be an important target for preventive efforts.

Difficulties with eating are common after stroke and are often associated with communication problems. Although numerous aspects of dysfunction have been identified, little is known about the experiences of living with eating difficulties after stroke. A few researchers have attempted to explore how best to ensure that the voices of people with communication impairment can be captured in qualitative research interviews, but several methodological issues related to including this population in qualitative research have remained unexamined. The purpose of the thesis was to illuminate the phenomenon of eating difficulties after stroke and to discuss methodological issues involved in interviewing persons with communication impairment. Study I had a qualitative, descriptive design involving repeated interviews and participant observations with three persons 1½ years post-stroke. Eating difficulties after stroke were experienced as Striving to live a normal life with the sub-themes Abandoned to learn on one’s own, Experiences of losses, and Feeling dependent. The findings showed that “eating difficulties after stroke” is a complex phenomenon, and that, based on the experiences of stroke survivors, there is a need for health care professionals to develop and use methods for eating training and other forms of support during the continuum of care. The combination of repeated interviews and participant observations seemed to be an approach that should be tested in larger studies. Study II was a methodological exploration based on the experiences gained in Study I and in a qualitative study involving persons with traumatic brain injury. Methodological issues related to sampling, obtaining informed consent, and fatigue in participant and researcher were discussed, and strategies for conducting qualitative interviews with these populations were suggested.

BACKGROUND: Previous studies have shown that eating difficulties after stroke are common and often associated with communication problems. These difficulties, however, have mainly been studied from a professional perspective. Although numerous aspects of dysfunction have been identified, little knowledge exists about the experiences of living with eating difficulties. AIM: To explore how people affected by stroke experience living with eating difficulties, during a prolonged period. DESIGN: Explorative, qualitative case study. METHODS: Repeated interviews and participant observations with three persons 1.5-2 years after their last stroke. Data were analysed using qualitative analysis. RESULTS: Eating difficulties after stroke were experienced as Striving to live a normal life, with the subthemes Abandoned to learn on one's own, Experiences of losses and Feeling dependent. The process of getting back to a life that resembled life before the stroke was experienced as long-lasting and hard work. The informants felt that they were abandoned to manage eating training on their own. The informants experienced a loss of functional eating ability and the ability to perform activities related to food and meals. Feelings of dependence were experienced in mealtime situations. CONCLUSION: Living with eating difficulties after stroke is a complex phenomenon. The informants felt abandoned because of lack of support from the nursing staff. They were left on their own to deal with the difficult process of adjusting to a new way of eating and losses regarding mealtime activities. The combination of repeated interviews and participant observations seemed to be an approach that should be tested in larger studies. RELEVANCE TO CLINICAL PRACTICE: This case study indicates a need for nurses to develop and use evidence-based guidelines for eating training during the continuum of care. Nurses need to assess patient's habits and desires related to eating, and to adjust environment according to patient preferences.

Qualitative research has made a significant contribution to the body of knowledge related to how people experience living with various chronic diseases and disabilities, however, the voices of certain vulnerable populations, particularly those with impairments that affect their ability to communicate, are commonly absent. In recent years, a few researchers have attempted to explore the most effective ways to ensure that the voices of people with communication impairments from acquired brain damages can be captured in qualitative research interviews, yet several methodological issues related to including this population in qualitative research remained unexamined. In this article, the authors draw on insights derived from their research on the experiences of adult survivors of stroke and traumatic brain injury to describe methodological issues related to sampling, informed consent, and fatigue in participant and researcher while also making some recommendations for conducting qualitative interviews with these populations.

Syftet med studien var att undersöka vad som påverkar valet av fritidsaktiviteter hos personer som haft stroke och på vilket sätt fritidsaktiviteterna har förändrats. För att uppnå syftet valdes kvalitativa intervjuer som metod. Intervjuerna var semistrukturerade och utgick från en egengjord intervjuguide. Resultatet visade att utmaningen, gemenskapen, fysisk träning, självständighet, balans i vardagen, livssynen och rehabiliteringsteamet var faktorer som påverkade deltagarnas utförande av fritidsaktiviteter. Att anpassa fritidsaktiviteten eller att få personligt stöd var vanligare än att anpassa den fysiska miljön.

När anhöriga drabbas av ett svårt trauma eller plötsligt dödsfall kan deras liv vändas upp och ned och bli kaotiskt. I en sådan situation är det oftast sjuksköterskan de anhöriga möter först. Syftet med denna studie är att beskriva vad sjuksköterskans stödjande roll gentemot anhöriga vid ett svårt trauma eller plötsligt dödsfall innefattar. Metoden som ligger till grund för studien är en deskriptiv litteraturstudie. Resultatet visar på olika behov hos anhöriga vid trauma eller plötsligt dödsfall. De anhöriga vill ha kontinuerlig information om patientens tillstånd och bra kommunikation mellan sig och vårdpersonalen. Utifrån sjuksköterskans perspektiv visas att hon/han använder sig av uppmuntran, stöttning, närhet och att främja välbefinnande som stödjande strategier för att tillgodose anhörigas behov. Slutsatsen är att sjuksköterskan kan, genom kunskap om anhörigas behov, skapa de bästa möjliga förutsättningarna för ett bra samarbete mellan vårdpersonal och anhöriga.

The aims of this study were, in a group of adolescents, firstly to identify the absolute heart rates (HR) and the percentages of maximal heart rates (HRmax) corresponding to 40%, 60% and 80% of peak oxygen uptake (PVO2), secondly to identify absolute and relative (%PVO2) oxygen uptakes (VO2) corresponding to HR of 120, 140 and 160 beats.min-1, and thirdly to examine a possible effect of fatness and fitness on the relationship between HR and VO2. The subjects were 127 (60 boys, 67 girls) adolescents with a mean age of 14.8 (SD 0.3) years. The HR and VO2 were measured by means of an incremental exercise test to exhaustion. Linear regressions were performed for the HR-VO2 and VO2-HR relationships using absolute and relative (%HRmax, %PVO2) data for each individual. From these regressions, target HR and VO2 were computed. Average target HR corresponding to 40%, 60% and 80% of PVO2 were: 119 (SD 9), 145 (SD 9), 171 (SD 8), and 120 (SD 10), 146 (SD 8), 172 (SD 8) beats.min-1 for boys and girls, respectively. Average VO2 corresponding to HR of 120, 140 and 160 beats.min-1 were: 22 (SD 5), 30 (SD 5), 38 (SD 6) and 18 (SD 4), 24 (SD 4), 31 (SD 4) mlO2.kg-1.min-1 for boys and girls, respectively. An analysis of covariance showed a significant fitness effect (P < 0.001) for predicted VO2 at all HR studied. The results suggest that the use of absolute HR to define exercise intensity levels when assessing young people's physical activity using HR monitoring detracts from the validity of the interpretation of the data.

In general, patient participation is regarded as being informed and partaking in decision making regarding one’s care and treatment. This interpretation is common in legislation throughout the Western world and corresponding documents guiding health care professionals, as well as in scientific studies. Even though this understanding of the word participation can be traced to a growing emphasis on individuals’ autonomy in society and to certain dictionary defi nitions, there are other ways of understanding participation from a semantic point of view, and no trace of patients’ descriptions of what it is to participate can be found in these definitions.

Hence, the aim of this dissertation was to understand patients’ experience of the phenomenon of patient participation. An additional aim was to understand patients’ experience of non-participation and to describe the conditions for patient participation and non-participation, in order to understand the prerequisites for patient participation.

The dissertation comprises four papers. The philosophical ideas of Ricoeur provided a basis for the studies: how communication can present ways to understand and explain experiences of phenomena through phenomenological hermeneutics. The first and second studies involved a group of patients living with chronic heart failure. For the fi rst study, 10 patients were interviewed, with a narrative approach, about their experience of participation and non-participation, as defi ned by the participants. For the second study, 11 visits by three patients at a nurse-led outpatient clinic were observed, and consecutive interviews were performed with the patients and the nurses, investigating what they experience as patient participation and non-participation. A triangulation of data was performed to analyse the occurrence of the phenomena in the observed visits. For paper 3 and 4, a questionnaire was developed and distributed among a diverse group of people who had recent experience of being patients. The questionnaire comprised respondent’s description of what patient participation is, using items based on findings in Study 1, along with open-ended questions for additional aspects and general issues regarding situations in which the respondent had experienced patient participation and/or non-participation.

The findings show additional aspects to patient participation: patient participation is being provided with information and knowledge in order for one to comprehend one’s body, disease, and treatment and to be able to take self-care actions based on the context and one’s values. Participation was also found to include providing the information and knowledge one has about the experience of illness and symptoms and of one’s situation. Participation occurs when being listened to and being recognised as an individual and a partner in the health care team. Non-participation, on the other hand, occurs when one is regarded as a symptom, a problem to be solved. To avoid non-participation, the information provided needs to be based on the individual’s need and with recognition of the patient’s knowledge and context.

In conclusion, patient participation needs to be reconsidered in health care regulations and in clinical settings: patients’ defi nitions of participation, found to be close to the dictionaries’ description of sharing, should be recognised and opportunities provided for sharing knowledge and experience in two-way-communication.

BackgroundThe legislation of many Western countries emphasizes active patient participation. Patients with chronic heart failure (CHF), however, have experienced participation differently from the general interpretation of legal definitions. Education improves uptake of self-management strategies yet knowledge is lacking about support of patients' own resources in CHF.

AimTo explore the phenomena of patient participation and non-participation as shown in patient visits to a nurse-led clinic for CHF and as experienced by the patients and nurses.

MethodsData triangulation of field notes from participatory observations and texts from narrative interviews with the patients and assigned nurse specialists. Data were analyzed according to the phenomenological hermeneutic tradition.

FindingsPatients' experience of participation and non-participation was interpreted as “Being responsible and accepting responsibility” and “Lacking an equal relationship while being controlled”, respectively. Nurses experienced patient participation as “Getting information and security to act” and patient non-participation as “Not accepting”.

ConclusionConflicting values of patients and nurses, which were interpreted with respect to participation and non-participation, presumably might influence patient information and education negatively. The issue of participation should be raised as a means of attaining concordance and to facilitate patient participation with education specifically tailored to the individual patient's needs.

Background: Patient participation is stressed in the health care acts of many western countries yet a common definition of the concept is lacking. The understanding of experiences of patients with chronic heart failure (CHF) who attend nurse-led specialist clinics, a form of care suggested as beneficiary to this group, may promote a better understanding of participation. Aim: To investigate the meanings of participation and non-participation as experienced by patients living with CHF. Methods: Narrative interviews analysed in the phenomenological hermeneutic tradition inspired by Ricoeur where the interpretation is made in the hermeneutic circle, explaining and understanding the experienced phenomena. Findings: Participation was experienced as to “be confident”, “comprehend” and “seek and maintain a sense of control”. Non-participation was experienced as to “not understand”, “not be in control”, “lack a relationship” and “not be accountable”. The findings indicate that the experiences of participation and non-participation can change over time and phases of the disease and treatment. Conclusion: The study suggests an extended view on the concept of participation. Patients' experiences of participation in health care can vary and should therefore be an issue for dialogue between nurses and patients with CHF in nurse-led specialist clinics.

This study explored patients' experiences of participation and non-participation in their health care. A questionnaire-based survey method was used. Content analysis showed that conditions for patient participation occurred when information was provided not by using standard procedures but based on individual needs and accompanied by explanations, when the patient was regarded as an individual, when the patient's knowledge was recognized by staff, and when the patient made decisions based on knowledge and needs, or performed self-care. Thus, to provide conditions for true patient participation, professionals need to recognize each patient's unique knowledge and respect the individual's description of his or her situation rather than just inviting the person to participate in decision making.

När alkoholen kommer närmare

- om förändrad alkoholtillgänglighet i en mindre svensk kommun

En kvalitativ intervjustudie

Ulrika Englund

Örebro Universitet, Hälsovetenskapliga institutionen

SAMMANFATTNING

Denna studie syftar till att undersöka vad som händer i en kommun när alkoholtillgängligheten förändras, och detta med utgångspunkt i kommunens alkoholförebyggande arbete. En specifik tonvikt har lagts vid kommunens etablering av ett Systembolag. Följande perspektiv har studerats; 1) Beskrivningar av förebyggande arbete 2) Exempel på alkoholförebyggande arbete 3) Samverkan 4) Viktiga aktörer 5) Alkoholkällor 6) Möjligheter till tillgänglighetsbegränsning samt 7) Systembolagets betydelse för kommunen.

Datainsamling skedde genom nio halvstrukturerade intervjuer med totalt tretton intervjupersoner vilka alla kom i kontakt med alkoholfrågan i sina arbeten. Intervjupersonerna kom att representera socialtjänst, kommun, skola, landsting, polis, Systembolaget, Brottsförebyggande rådet och nattvandrarverksamheten i den studerade kommunen. Insamlad intervjudata bearbetades med meningskoncentrering.

Resultatet visar att ett omfattande alkoholförebyggande arbete bedrivs inom kommunen. Huvudsaklig fokus ligger på ungdomar och dess föräldrar och arbetet är ofta praktiskt inriktat på att försöka försena ungdomars alkoholdebut. Samverkan i alkoholrelaterade frågor pågår i stor utsträckning och många viktiga aktörer identifieras. Gruppen föräldrar bedöms vara den allra viktigaste parten i alkoholförebyggande sammanhang.

Importerad alkohol beskrivs som vanligast i samband med ungdomars konsumtion och som den mest allvarliga och svårkontrollerade alkoholkällan. Systembolagets etablering i kommunen uppfattas som positiv. Någon konsumtionsökning eller ökad mängd alkoholrelaterade problem på grund av etableringen kan inte urskiljas. Systembolaget utgör ett viktigt led i tillgänglighetsbegränsningen med ålderskontrollen för alkoholinköp som den viktigaste uppgiften. Såväl den hembrända alkoholen som den offentliga ungdomsberusningen bedöms vara mindre förekommande än tidigare.

Nyckelord: alkohol, förebyggande, ungdomar, Systembolaget, import, begränsning