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Persons with severe mental ill-health die early from preventable physical ill-health. Registered nurses in psychiatric outpatient care play a key role in improving persons’ physical health, and it is important to examine how they view their responsibility, their experiences of care, and the obstacles they meet in providing person-centred care. The purpose of this study was to explore registered nurses’ experiences of caring for persons with mental ill-health and somatic comorbidity in psychiatric outpatient care, using qualitative content analysis to analyze data from semi-structured interviews. The results show that these nurses monitored the person’s right to equal care, embraced the whole of the persons suffering, and dealt with unclear boundaries in care. This highlights the unique role that registered nurses play in psychiatric outpatient care via their ability to interpret symptoms and find ways to adapt care based on persons’ needs. Registered nurses consider physical health in all care and provide a link between psychiatric and somatic care. Together with mental health nurses at primary health care centers, they are key in reducing persons’ suffering. There is a need for structural and functional changes in line with person-centred care including collaboration both within and outside healthcare organizations.

People with severe mental ill-health have lower life expectancies than the rest ofthe population, partly due to unhealthy lifestyles. Counselling to help these people improve their health can also be complex, and registered nurses are key to its success.The aim of this study was to elucidate registered nurses' experiences of providing health counselling to people living with severe mental ill-health in supported housing. We conducted eight individual semi-structured interviews with registered nurses working in this context and subjected the responses to qualitative content analysis. The results show that registered nurses who counsel people with severe mental ill-health feel dispirited, but they defend their often fruitless endeavours and strive, through health counselling, to help these people meet healthier lifestyle goals. Shifting the focus from traditional health counselling to person-centred care using health-promoting conversations could strengthen registered nurses in their efforts towards improving lifestyles among people living with severe mental ill-healthin supported housing. Therefore, to facilitate healthier lifestyles among this population, we recommend that community healthcare support registered nurses working in supported housing by educating them in the use of health-promoting conversations, including teach-back techniques.

Around 15% of the world’s population lives with some form of functional and/or intellectual disability (FID). Nursing staff often face threats and violence in the care of patients with FID. This study aimed to illuminate registered nurses’ experiences of challenging situations in their psychosocial working environment in home care of patients with functional and/or intellectual disabilities. Nine registered nurses/district nurses working in municipal settings were interviewed using a qualitative approach. COREQ was used for explicit and comprehensive reporting of qualitative studies. Three categories were revealed: To face challenging behaviour, To face emotional burden and To face communication difficulties. Nurses need continuous training and support to cope with work-related stress to meet a person with FID in a calm and relaxed mood and to be prepared for critical situations in their psychosocial environment. Training and support may enable nurses to be in a state of harmony and to be present in order to build caring relationships.

Providing care and support to persons with intellectual disabilities (ID) requires in-depth knowledge about ID and challenging behaviour (CB) as well as communication and interaction. Knowledge deficiencies in these areas may prevent staff from understanding their clients and their behaviours, particularly those behaviours considered to be challenging. The aim of this study was to explore staff’s perceptions about CB among clients with ID in residential settings before and after a web-based training programme using the survey instrument 'Checklist of Challenging Behaviour' (CCB). The CRe-DEPTH guideline has served as a guide in this study. Upon completion of the training, staff perceived a reduced frequency of CB as well as reduced management difficulty of CB among clients. As such, training should routinely be offered to all staff in residential settings, but also healthcare professionals in general responsible for caring for clients exhibiting CB to ensure, improve and reinforce the quality of care and support provided to them.

Chemical restraints are used in forensic psychiatric inpatient care, however with caution as it can feel like an assault against patients' integrity. When waiting for decisions on treatment without consent, nursing staff are expected to care for patients with severe mental ill-health without the use of medical treatment, often with a feeling of already having tried all other available means. Knowledge about how registered nurses experience such situations is sparse but could contribute to the development of both teamwork and nursing approaches that could mean reduced suffering for patients. The aim of this study was to describe registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care. Eleven semi-structured interviews were conducted with registered nurses working in forensic psychiatric units in Sweden. Data were analysed through qualitative content analysis. The result showed that experiences of treatment without consent were about striving to protect patients from harm, striving for collaboration during difficult circumstances and striving to do good. This was interpreted as a struggle with unnecessary suffering. For registered nurses to be able to handle such challenging situations and relieve suffering for patients, experience and master-level education in mental health nursing are highlighted. Another aspect that is highlighted is the importance of having consultants familiar with the circumstances at the unit. A method for joint reflection is suggested, to promote an open-minded work culture with a well-functioning decision-making process and ensure that both consultants and nursing staff have support.

Background: Clear and effective communication is a prerequisite to provide help and support in healthcare situations, especially in health, and social care services for persons with intellectual disabilities, as these clients commonly experience communication difficulties. Knowledge about how to communicate effectively is integral to ensuring the quality of care. Currently, however, there is a lack of such knowledge among staff working in the disabilities sector, which is exacerbated by challenges in the competence provision in municipal health and social care services. Therefore, the aim of the study was to explore staffs' experience of web-based training in relation to their professional caring for persons with intellectual disabilities and challenging behavior. The intention is to move toward well-evaluated and proven web-based training in order to contribute to competence provision in this specific context.

Methods: Fourteen semi-structured interviews were carried out with individual staff members to gather data regarding their experiences with web-based training in relation to their profession. The collected data were analyzed using qualitative content analysis with a focus on both manifest and latent content.

Results: The staff's experiences with the web-based training program were presented as a single main theme: “Web-based training for staff initiates a workplace learning process by promoting reflections on and awareness of how to better care for persons with intellectual disabilities and challenging behavior.” This theme contained three categories which are based on eight sub-categories.

Conclusion and clinical implications: The benefits of web-based training for workplace learning could clearly be observed in the strengthening of professional care for persons with intellectual disabilities and challenging behavior. Staff members claimed to have gained novel insights about how to better care for clients as well as about the importance of interactions in their encounters with clients. Professional teamwork is crucial to providing effective care for persons with intellectual disabilities and challenging behavior. Hence, future research aimed at investigating the views of other healthcare professionals, such as registered nurses, is recommended to improve the competence provision within municipal health and social care services and thereby enhance the quality of care.

Objective: We evaluated school nurses' attitudes towards family involvement in school healthcare when children exhibit signs of mental health problems.

Methods: In a cross-sectional study, the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) instrument was used to measure school nurses' (N = 133) attitudes towards family involvement. Data were analyzed with the Mann-Whitney U-test.

Results: School nurses (95%) encountered students with mental health problems every day or every week. Overall, school nurses were positive towards family involvement in school healthcare. Primary school nurses were more positive compared to secondary school nurses, seeing the family as a resource and a conversation partner. School nurses who felt that they had insufficient tools to work with children with mental health problems saw the family as a burden compared to school nurses who reported they have sufficient tools.

Conclusion: School nurses' attitudes toward involving families as a resource are promising. However, when nurses perceive themselves as lacking sufficient tools to respond to children's mental health problems, they are more likely to experience the family as a burden than a resource. Cooperation between school nurses and families may be crucial. Therefore, we suggest a Family Health Conversations model to improve nurse-family collaboration

AIMS AND OBJECTIVES: To describe the perceptions that municipal primary healthcare nurses and municipal registered nurses had about a web-based learning intervention concerning supportive family health conversations in municipal home health care.

BACKGROUND: Even though family health conversations are well grounded in theory with several reported benefits for patients and families, most working nurses have little or no training in practising family systems nursing including family health conversations. Continued learning is necessary for nurses, where web-based learning may be one answer of updating the professional skills and knowledge of nurses regarding supporting families.

DESIGN: The study used a descriptive design and followed the "Consolidated criteria for reporting qualitative research" (COREQ) checklist.

METHODS: Twenty-one nurses participated in an educational intervention that consisted of web-based learning and two face-to-face seminars about family systems nursing including family health conversations. The nurses were interviewed after completion, and the audio-recorded interviews were transcribed verbatim and analysed using qualitative content analysis.

RESULTS: The findings consist of nurses' perceptions regarding the disposition of instruction, the prerequisites for learning and a changed approach when working with families. The findings are further reflected on through Illeris' theory concerning learning triangle.

CONCLUSIONS: The findings are encouraging for educating nurses in family health conversations at their workplace, with the purpose of supporting patients and families. However, it is important to be aware of the different dimensions of learning, in addition to the appraisal of social aspects and organisational circumstances when educating nurses as they influence the utilisation of the knowledge.

RELEVANCE TO CLINICAL PRACTICE: This web-based learning intervention seems to be suitable for educating nurses in family health conversations and could be an appropriate step towards implementing these conversations in home health care with the purpose of supporting families.

The interaction between people with intellectual disabilities and professional carers is often influenced by communicative difficulties contributing challenging behaviours. The aims of this study were to evaluate to a web-based training program aimed at improving carers' abilities to interact with people with learning disabilities who exhibit challenging behaviours and to explore carers' experiences of participating in such a program. A single-subject experimental design and mixed methods were used to integrate qualitative and quantitative data. Triangulation of questionnaires, interviews with carers, and assessments of one woman's behaviour was performed. The participants were professional carers aged 20 to 55 years. The web-based training program increased carers' abilities to handle challenging behaviours and decreased challenging behaviours in daily care. The program improved the opportunities to offer training to carers who work in community-based accommodations with limited time to receive training.

Bakgrund: Många personer med utvecklingsstörning har kommunikativa svårigheter och har därför behov av att utveckla olika sätt att kommunicera för att kunna förstå andra och göra sig förstådda. Svårigheter i kommunikationen påverkar interaktionen mellan personer med utvecklingsstörning och deras vårdare. Detta ställer höga krav på vårdare att kunna tolka och förstå den enskilda individens sätt att uttrycka önskningar och behov. På samma sätt riskerar vårdares budskap att missförstås. Om vårdaren misslyckas att förstå den boendes kommunikation och vice versa, kan det leda till situationer med utmanande beteende exempelvis i form av vägran, verbal eller fysisk aggressivitet.

Syfte: Det övergripande syftet med avhandlingen är att studera interaktion mellan vuxna personer med utvecklingsstörning och vårdare i gruppbostäder, samt att studera effekter av en utbildningsintervention för vårdare som arbetar i gruppbostäder.

Metod: Avhandlingens samtliga delstudier har genomförts i gruppbostäder för personer med utvecklingsstörning bland boende och vårdare i ett län i norra Sverige. I studie I insamlades data kring 556 personer med utvecklingsstörning. I studie II och III deltog 16 vårdare och 11 personer med utvecklingsstörning. I studie IV deltog 7 vårdare. Studie I bygger på personalens skattningar av funktionsnivåer och förekomst av begränsningsåtgärder. I Studie II och III utgörs data av videoobservationer och narrativa intervjuer. I studie IV användes flera datainsamlingsmetoder i en mixed method design med både vårdarnas skattningar, med hjälp av instrument och semi-strukturerade intervjuer. Analys av materialet i studie II, III och IV har gjorts med kvalitativ innehållsanalys och i studie I och IV har data analyserats statistiskt.

Resultat: I studie I framkom att av 556 boende hade 99 (18%) varit föremål för fysiska begränsningsåtgärder under den senaste veckan. Av dessa 99 hade nästan alla varit föremål för mer än en typ av begränsningsåtgärd. Den vanligaste begränsningsåtgärden var bälte i stol (74%). Användningen av begränsningsåtgärder var relaterade både till fysiska funktionsnedsättningar och till beteende.

I studie II reflekterade vårdare över videoinspelad interaktion där vårdarna medverkat, både framgångsrik och misslyckad interaktion. Exempel på framgångsrik interaktion var att förstå tecken, kunna möta behov och hantera situationer med utmanande beteenden. Vårdarna reflekterade över att framgångsrik interaktion ledde till säkerhet, trygghet och självförtroende hos de boende. Vårdarna reflekterade även över de konsekvenser misslyckad interaktion fick i form av irritation, aggression och våld från de boende.

I studie III studerades videoinspelad interaktion mellan 11 personer med utvecklingsstörning och 16 av deras vårdare. Verbal och icke-verbal interaktion identifierades. Fyra inspelade situationer valdes ut för att belysa framgångsrikt samspel. Resultatet visade att framgångsrikt samspel mellan personer med utvecklingsstörning och deras vårdare bland annat bygger på möjligheten att bekräfta varandra, dela vardagshändelser, ge tid och utrymme och på att använda ett kongruent och tydligt språk.

I studie IV utvärderades effekterna av en web-baserad utbildningsintervention, vars syfte var att förbättra interaktionen mellan personer med utvecklingsstörning och vårdare samt att därmed reducera förekomsten av situationer med utmanande beteende. Resultatet visade att vårdarna hade förbättrat sin förmåga att hantera situationer med utmanande beteende och att förekomsten av utmanande beteende minskat. Vårdarna beskrev att den web-baserade utbildningen upplevts givande och möjlig att ta del av parallellt med arbetet.

Slutsats: Fysiska begränsningsåtgärder förekommer i gruppbostäder för personer med utvecklingsstörning. Användningen av begränsningsåtgärder kan vara relaterade både till fysiska funktionsnedsättningar och till beteenden i samspelet mellan brukare och vårdare. Vårdare upplever användningen av fysiska begränsningsåtgärder svår och tröttande. Brott i kommunikationen mellan personer med utvecklingsstörning och deras vårdare kan leda till försvårad interaktion med risk för situationer med utmanande beteenden. När vårdare är framgångsrika i interaktionen med personer med utvecklingsstörning ger det tillfredsställelse både för de boende och vårdarna. Vårdarna upplever dock ofta hjälplöshet och osäkerhet i relation till hantering av situationer med utmanande beteende och efterfrågar utbildning. Web-baserad utbildning om interaktion med personer med utvecklingsstörning och utmanande beteende har i vår studie visat sig ge lovande effekter och bör vara möjlig att utveckla för både introduktion av nyanställda vårdare och för kompetensutveckling bland mer erfaren personal.

Background: People with learning disabilities communicate in various ways depending on their abilities. Communication difficulties affect interactions between people with learning disabilities and their professional carers’ and this places a high demand on the carers to interpret and understand each individual’s wishes and needs. At the same time, there is a risk that the carers will be misunderstood. If carers fail to understand what the residents are trying to communicate, and vice versa, situations with challenging behaviour such as an unwillingness to interact or verbal and physical aggression may occur.

Aim: The overall aim of this thesis was to explore the interactions between adults with learning disabilities and carers in special accommodations as well as to evaluate the effects of an intervention created for carers working with people with learning disabilities at special accommodations.

Method: The setting for the study was at special accommodations in one county in northern Sweden. In study I, information regarding 556 adults with learning disabilities was collected. In both study II & III, 11 people with learning disabilities and 16 of their carers participated. In study IV, 7 carers and one person with learning disabilities participated. Data in study I consist of carers’ estimations of the residents disabilities and frequency of restraint use. Video-recorded observations and individual narrative interviews were used in study II and study III, and in study IV multiple methods of data collection were used in a mixed method design with both carers’ estimations using instruments and with semi-structured interviews. Methods for analyses in study II, III and IV were qualitative content analysis and in study I and IV statistical analyses were used.

Results: Study I revealed that of the 556 residents studied, 99 (18%) had been subjected to physical restraint use over the previous week. Of these participants, almost all were subjected to more than one type of restraint. The most commonly used physical restraint was a belt in chair (74%). Use of physical restraint can be related to both physical disabilities and challenging behaviours in the interaction between people with learning disabilities and their carers’. In interviews for study II, the carers reflected on both successful and unsuccessful interactions after viewing video of situations where they have been participating. Examples of successful interactions included understanding cues, satisfying needs, and managing situations with challenging behaviours. The carers’ reflected on how successful interactions could influence their feeling of security, confidence, and satisfaction among the residents. The carers also reflected on the consequences of unsuccessful interactions, which included causing irritation, aggression and violence. In study III, interactions between 11 residents with learning disabilities and 16 of their caregivers were recorded on video. Verbal and non-verbal interaction skills used among the carers were identified. Four ‘caring situations’ were chosen as examples of skilled interactions. The results showed that skilled interactions between the carers and their clients were based on being confirming, sharing daily life experiences, giving time and space, and using congruent and distinct language. Study IV evaluated the effects of a web-based learning intervention, based on a theoretical model, and the results showed an increased ability among the carers to handle situations with challenging behaviour and a decreased frequency of challenging behaviour.

Conclusion: Physical restraint is commonly used in special accommodations for people with learning disabilities. Use of physical restraint can be related to both physical disabilities and challenging behaviours in the interaction between people with learning disabilities and their carers. Carers find the use of physical restraint difficult and exhausting. A break in communication between people with learning disabilities and their carers could lead to impaired interaction that creates situations of challenging behaviour. When carers are able to interact successfully with people who have limited ability to communicate verbally, it seems to give satisfaction to both the residents and their carers in group homes. Carers often experience helplessness and uncertainty in situations with challenging behaviour and express a need for support. The carers considered the web-based training program to be useful. Further, a decrease of situations of challenging behaviour was observed after the web-based program was implemented. This indicates that the web-based training program may be useful in training for carers, both novices and more experienced carers in special accommodations for people with learning disabilities