Astrid Norberg

Person-Centered Care — Ready for Prime Time

Long-term diseases are today the leading cause of mortality worldwide and are estimated to be the leading cause of disability by 2020. Person-centered care (PCC) has been shown to advance concordance between care provider and patient on treatment plans, improve health outcomes and increase patient satisfaction. Yet, despite these and other documented benefits, there are a variety of significant challenges to putting PCC into clinical practice. Although care providers today broadly acknowledge PCC to be an important part of care, in our experience we must establish routines that initiate, integrate, and safeguard PCC in daily clinical practice to ensure that PCC is systematically and consistently practiced, i.e. not just when we feel we have time for it. In this paper, we propose a few simple routines to facilitate and safeguard the transition to PCC. We believe that if conscientiously and systematically applied, they will help to make PCC the focus and mainstay of care in long-term illness.

Acute Confusional States in Elderly Patients Treated for Femoral Neck Fracture

The aims of this study were to estimate the incidence of acute confusional state (ACS), its predisposing factors and consequences in 111 consecutive patients operated for fractured neck of the femur. The incidence of ACS was 61 percent and the predicting factors were old age and dementia. Drugs with anticholinergic effect, depression, and previous stroke were factors that seemed to be associated with the development of ACS. Ninety‐two percent of the patients who had severe perioperative blood pressure drops developed ACS. The consequences of ACS were prolonged ward‐stay at the orthopedic department, a greater need for long‐term care after discharge, and poor walking ability at discharge and six months after surgery. The confused patients also had more complications, such as urinary problems, feeding problems and decubital ulcers, as compared with the nonconfused patients.

Resilience, sense of coherence, purpose in life and self-transcendence in relation to perceived physical and mental health among the oldest old.

Different concepts have been presented which denote driving forces and strengths that contribute to a persons ability to meet and handle adversities, and keep or regain health. The aim of this study, which is a part of The Umeå 85+ study, was to describe resilience, sense of coherence, purpose in life and self-transcendence in relation to perceived physical and mental health in a sample of the oldest old. The study sample consisted of 125 participants 85 years of age or older, who ranked themselves on the Resilience Scale, Sense of Coherence Scale, Purpose in Life Scale and Self-Transcendence Scale and answered the SF-36 Health Survey questionnaire. The findings showed significant correlations between scores on the Resilience Scale, the Sense of Coherence Scale, the Purpose in Life Test, and the Self-Transcendence Scale. Significant correlations were also found between these scales and the SF-36 Mental Health Summary among women but not among men. There was no significant correlation between perceived physical and mental health. The mean values of the different scales showed that the oldest old have the same or higher scores than younger age groups. Regression analyses also revealed sex differences regarding mental health. The conclusions are that, the correlation between scores on the different scales suggests that the scales measure some dimension of inner strength and that the oldest old have this strength at least in the same extent as younger adults. Another conclusion is that the dimensions that constitute mental health differ between women and men.

The meaning of the lived experience of hope in patients with cancer in palliative home care

The aim of this study was to illuminate the meaning of the lived experience of hope in patients with cancer in palliative home care. Narrative interviews with 11 patients were interpreted using a phenomenological–hermeneutic method, inspired by Ricoeur. The findings revealed a tension between hoping for something, that is a hope of getting cured, and living in hope, that is reconciliation and comfort with life and death. This tension is highlighted, according to the views of the French philosopher Gabriel Marcel, as a state of ‘recollection’. The interviewees told of the hope of living as normally as possible and of the experience of confirmative relationships as dimensions of their lived experience of hope. These findings show that hope is a dynamic experience, important to both a meaningful life and a dignified death, for those patients suffering from incurable cancer.

A Geriatric-Anesthesiologic Program To Reduce Acute Confusional States in Elderly Patients Treated for Femoral Neck Fractures

The aim of this study was to evaluate the effect of a geriatrk‐anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre‐ and post‐operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri‐operative blood pressure falls and treatment of post‐operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P < 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post‐operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P < 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.

Underdiagnosis and Poor Documentation of Acute Confusional States in Elderly Hip Fracture Patients

To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture.

Struggling for Dignity: The Meaning of Women’s Experiences of Living with Fibromyalgia

Fibromyalgia (FM) is a common chronic pain syndrome with an obscure etiology, which mostly afflicts middle-aged women. In this study, 14 women with FM were interviewed about the meaning of living with the illness. A phenomenological-hermeneutic method was used to analyze and interpret the interview texts. The findings show that being a woman with FM means living a life greatly influenced by the illness in various ways. The women’s experiences of living with FM were presented in three major interlaced themes: loss of freedom, threat to integrity, and a struggle to achieve relief and understanding. This study highlights the importance of meeting people suffering in illness with respect for their human dignity. The care of women with FM must empower the women to bring to bear their own resources so that they can manage to live with the illness.

Developing the Concept of Moral Sensitivity in Health Care Practice

The aim of this Swedish study was to develop the concept of moral sensitivity in health care practice. This process began with an overview of relevant theories and perspectives on ethics with a focus on moral sensitivity and related concepts, in order to generate a theoretical framework. The second step was to construct a questionnaire based on this framework by generating a list of items from the theoretical framework. Nine items were finally selected as most appropriate and consistent with the research team’s understanding of the concept of moral sensitivity. The items were worded as assumptions related to patient care. The questionnaire was distributed to two groups of health care personnel on two separate occasions and a total of 278 completed questionnaires were returned. A factor analysis identified three factors: sense of moral burden, moral strength and moral responsibility. These seem to be conceptually interrelated yet indicate that moral sensitivity may involve more dimensions than simply a cognitive capacity, particularly, feelings, sentiments, moral knowledge and skills.

Development and Initial Validation of the Stress of Conscience Questionnaire

Stress in health care is affected by moral factors. When people are prevented from doing ‘good’ they may feel that they have not done what they ought to or that they have erred, thus giving rise to a troubled conscience. Empirical studies show that health care personnel sometimes refer to conscience when talking about being in ethically difficult everyday care situations. This study aimed to construct and validate the Stress of Conscience Questionnaire (SCQ), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. The items were based on situations previously documented as causing negative stress for health care workers. Content and face validity were established by expert panels and pilot studies that selected relevant items and modified or excluded ambiguous ones. A convenience sample of 444 health care personnel indicated that the SCQ had acceptable validity and internal consistency (Cronbach’s alpha exceeded 0.83 for the overall scale). Explorative factor analysis identified and labelled two factors: ‘internal demands’ and ‘external demands and restrictions’. The findings suggest that the SCQ is a concise and practical instrument for use in various health care contexts.

Health status in the oldest old. Age and sex differences in the Umeå 85+ Study.

Background and aims: With an increasing population aged 85 years and over, the aim of this study was to describe health status and living conditions in the oldest old and to estimate age and sex differences in a Northern European population. Methods: A population-based cross-sectional study, The Umeå 85+ Study, was carried out in the municipality of Umeå in northern Sweden. Out of 319 eligible participants aged 85, 90 and 95 years and over, 253 participated. Structured interviews and assessments were conducted with the participants in their homes, and data were also collected from relatives, caregivers and medical charts. Cognition was screened with the Mini-Mental State Examination (MMSE), depressive symptoms with the Geriatric Depression Scale-15 (GDS-15) and nutritional status with the Mini Nutritional Assessment (MNA). Activities of daily living (ADL) were assessed applying the Staircase of ADL (including Katz’ Index of ADL) and morale with the Philadelphia Geriatric Center Morale Scale (PGCMS). Participants also rated their own health. Results: Over half of the participants had hypertension, one out of four was depressed, and the same proportion had had a hip fracture; the mean number of drugs taken was 6.4±4.0. Younger participants had lower rates of diagnoses and prescribed drugs, and were less dependent in ADL and other functional variables; men had lower rates of diagnoses and reported symptoms. The majority of participants rated their general health and morale as good. Conclusions: There were large variations in social, medical and functional variables within and between age and sex groups. This northern population of the oldest old seems to have a very high prevalence of hypertension, depression, hip fractures, and many prescribed drugs.