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Lung cancer (LC) generally lacks unique core symptoms or signs. However, there are a multitude of bodily sensations that are often non-specific, not easily understood, and many times initially not recognized as indicative of LC by the affected person, which often leads to late diagnosis. In this international qualitative study, we inductively analyzed retrospective accounts of 61 people diagnosed with LC in Denmark, England and Sweden. Using the bodily sensations they most commonly spoke about (tiredness, breathlessness, pain, and cough), we constructed four sensation-based cases to understand the pre-diagnostic processes of reasoning and practice triggered by these key indicators of LC. We thereafter critically applied Hay's model of sensations to symptoms transformation, examining its central concepts of duration, disability and vulnerability, to support understanding of these processes. We found that while duration and disability are clearly relevant, vulnerability is more implicitly expressed in relation to perceived threat. Tiredness, even when of long duration and causing disability, was often related to normal aging, rather than a health threat. Regardless of duration, breathlessness was disturbing and threatening enough to lead to care-seeking. Pain varied by location, duration and degree of disability, and thus also varied in degree of threat perceived. Preconceived, but unmet expectations of what LC-related cough and pain would entail could cause delays by misleading participants; if cough lasted long enough, it could trigger health care contact. Duration, disability, and sense of threat, rather than vulnerability, were found to be relevant concepts for understanding the trajectory to diagnosis for LC among these participants. The process by which an individual, their family and health care providers legitimize sensations, allowing them to be seen as potential symptoms of disease, is also an essential, but varying part of the diagnostic processes described here.

AIM: This paper reports a study illuminating meanings of being in the physical environment of an oncology centre as narrated by patients, significant others and staff. BACKGROUND: The physical environment of hospitals can convey different messages. For example, landscape pictures, plants and comfortable chairs can convey positive messages, while sparsely decorated and run-down environments can convey negative values. Traditional healthcare environments may be experienced as unfamiliar, strange and alienating, fostering feelings of stress and vulnerability. The majority of research on care environments has employed experimental designs to test different environmental variables, for example sound, colour and architecture, in relation to patient outcomes such as recovery, pain and blood pressure. There is, however, little research-based understanding of the meanings of being in these environments. METHODS: A phenomenological hermeneutic approach was applied to analyse 17 interviews with patients, significant others and staff carried out during the spring of 2004 at an oncology centre in Sweden. FINDINGS: The physical environment was found to influence experiences of care in four ways: first, by being a symbol expressing messages of death and dying, danger, shame and stigma, less social value and worth; second by containing symbols expressing messages of caring and uncaring, life and death; third, by influencing interaction and the balance between being involved and finding privacy; and fourth, by containing objects that could facilitate a shift of focus away from the self: being able to escape the world of cancer, and finding light in the midst of darkness. The comprehensive understanding illuminates the physical environment as not merely a place for caring, but as an important part of caring that needs to be accounted for in nursing care. CONCLUSION: To promote well-being among patients, we need to ask ourselves if the environment imposes rather than eases suffering. Our findings also suggest the importance of not limiting our conceptions of nursing to nurse-patient relationships, but of using the therapeutic potential of the total environment in nursing care.

AIM: The aim of the study was to construct and evaluate psychometric properties of the Swedish language Person-centred Climate Questionnaire - staff version. BACKGROUND: Person-centred care is often quoted but ill defined, and the literature warrants the development of valid and reliable measurement tools. METHODS: During 2006, a questionnaire was constructed and distributed to a sample of Swedish hospital staff (n = 600). Questionnaire data was subjected to item analysis and reduction. Psychometrical properties of the questionnaire were evaluated. RESULTS: The 14-item Person-centred Climate Questionnaire showed satisfactory psychometric properties. Measures of validity were good, internal consistency was high, Cronbach's alpha was satisfactory for the total scale (0.88) and test-retest reliability was adequate. CONCLUSION: The results indicate that the staff Person-centred Climate Questionnaire is a valid and reliable tool for assessing staff perceptions of the person centredness of hospital environments. IMPLICATIONS FOR NURSING MANAGEMENT: This instrument makes it possible to study the degree of person-centredness in relation to different organizational systems, environments, staff groups and managerial styles. In addition, staff variables such as turnover rates, health outcomes and efficacy can be related to staff perceived person centredness of the organization.

Aims and objectives. This article present findings from a study aiming to explore the psychosocial climate and its influence on the well-being of people with dementia in a psycho-geriatric hospital unit.

Background. Environmental influence in dementia is well explored in relation to the physical environment; however, few studies have explored the psychosocial environment and its influence on well-being.

Design. The study had a grounded theory design.

Methods. Participant observations were conducted in a psycho-geriatric ward for assessment and treatment of people with dementia in Sweden (n = 36 hours). Data were collected and analysed in a dialectical fashion using the principles of grounded theory methodology.

Results. The basic social process that best accounted for the variation in the psychosocial climate and well-being of patients at the unit was 'staff presence or absence', conceptualised as the core category. Three categories emerged in relation to the core category; 'sharing place and moment', 'sharing place but not moment' and 'sharing neither place nor moment'.

Conclusions. Staff were catalysts for the psychosocial climate and when being present and engaged they could create a climate interpreted as at-homeness which supported patient well-being. When being absent, the climate quickly became anxious and this facilitated patient ill-being. To provide quality care for people with dementia staff need to be aware of their role in setting the emotional tone of the psychosocial climate and also that this emotional tone significantly influences patient well-being.

Relevance to clinical practice. The findings are clinically relevant and can be operationalised and applied in clinical practice. Awareness of the intimate connection between staff presence and absence, the psychosocial climate and patient well-being highlights an ethical responsibility to question: routines that promote staff absence; a culture of merely 'doing for'; and nursing tasks which involve a minimum of staff-patient interaction. The findings have implications for managers as well as for clinical staff.

AIM: This paper is a report of a study to construct and evaluate psychometric properties of the Swedish language patient version Person-centred Climate Questionnaire.

BACKGROUND: Person-centred care is widely described as a preferred model of care as it uses the individual person's perspective as point of departure. However, the concept is elusive and lacks definition and a means of measurement.

METHOD: A preliminary item pool generated from qualitative studies was distributed to a sample of hospital patients (n = 544) and subjected to item analysis and reduction using exploratory and confirmatory factor analysis. The psychometrical properties of the final questionnaire were evaluated using statistical estimates of validity and reliability.

RESULTS: The final 17-item questionnaire consists of three factors explaining 65.1% of the total variance in data, and shows satisfactory goodness-of-fit in confirmative factor analyses. The factors were labelled safety, everydayness and hospitality. Content and construct validity was estimated as satisfactory by Delphi assessment, factor and item analysis. Cronbach's alpha was satisfactory for the total scale (0.93), and also for the three subscales: safety 0.94, everydayness 0.82 and generosity 0.64.

CONCLUSION: The Person-centred Climate Questionnaire is a valid and reliable contribution for assessing to what extent the climate of hospital environments is person-centred. The instrument enables descriptions and comparisons of environments, exploration of correlates between person-centredness and patient outcomes and/or measure results of various interventions.

Breast cancer is the most common type of cancer among women. In Sweden, about 40% of women diagnosed with breast cancer undergo a mastectomy; breast reconstruction (BR) may be an option for these women. However, the experience of undergoing reconstructive surgery appears to be only very scarcely researched, despite its importance in clinical nursing.

Aim: The purpose of this study was to explore women's experiences of undergoing breast reconstructive surgery after mastectomy due to breast cancer.

Methods: Six women participated in narrative interviews about their experiences of reconstructive surgery, and the interview data were analysed using thematic narrative analysis.

Results: All six women were unprepared for the strenuous experience of undergoing a BR. They described the process as difficult and painful, entailing several operations and an unexpectedly long recovery period. They were also unprepared for how arduous it would be, both physically and emotionally. However, getting a BR had been important to all the women. The BR process was captured in four themes: (1) uninformed care; (2) arduous experiences; (3) body alterations; and (4) moving on.

Conclusions: Obtaining adequate information and being involved in the decision-making process along the pathway of a BR could help the women to prepare physically and emotionally for the strenuous experiences related to reconstructive surgery.

Aim: This study compares potential differences between women with breast cancer who after mastectomy had undergone breast reconstruction with those who had not. Material and methods: All women (N=149) in the northern medical region of Sweden who had undergone mastectomy in 2003 received a self-reported questionnaire entitled “Life After Mastectomy (LAM)” that included standardized measures of sociodemographic, decision-making process, breast reconstruction (BR) yes or no, sexuality, and body image. SPSS was used for data processing. Results: In total 85% of the women returned the questionnaire and of these 25% had undergone BR. In accordance with previous studies, we found that the mean age of the women in the BR group was significantly lower (52 vs. 64 years), they had a higher education, and a higher proportion were employed, influenced by the physician's opinion regarding BR, sexually active, and rated a negative impact concerning the factors attractiveness and body disclosure. A multiple regression analysis, however, showed that the choice to undergo breast reconstruction or not was only independently associated with age, feeling of attractiveness and sexual interest. Discussion: Age explained most differences found between the two groups. When researchers try to identify what differentiates the groups of women who undergo reconstruction between those who do not undergo reconstruction after mastectomy, it is thus necessary to take into consideration that the meanings of mastectomy, body image, attractiveness and similar variables may vary due to the phase of a woman's life. In conclusion, considering the impact of age is of paramount importance in future studies for our understanding of women's experiences.

Purpose: This 2-year follow-up study explores aspects of body image after mastectomy due to breast cancer.

Materials and Methods: This population-based study included 76 women living in northern Sweden who, during November 2006 to October 2007, underwent mastectomy due to breast cancer. The women completed a questionnaire entitled “Life After Mastectomy (LAM)” 10 months after the mastectomy and again 2 years later. We used SPSS version 18.0 for data processing and analysis.

Results:The findings indicate that few significant changes in body image had taken place during the 2-year interval between the first and second completion of the questionnaire. An exception was a significant decrease in feelings of sexual attractiveness and comfort during sexual intimacy. At follow-up, 21% of the women had undergone breast reconstruction (BR). They were significantly younger than the women who had not had BR (53 v. 63 years). Besides being younger, no other significant differences could be found between those women who had undergone BR and those who had not. The fact that the decrease in sexual attractiveness and feelings of comfort during sexual intimacy also applied to the subgroup of women who had had BR may therefore be surprising. A better understanding of issues related to breast cancer treatment and sexual function is vital.

Conclusion: It is important for health care professionals to be aware of problems related to sexual intimacy and to be prepared not just to provide information about these, but also to reflect on expectations v. reality together with the women.

Background: Because of early detection and advanced treatment options, more women with breast cancer survive after mastectomy and thus have to face the choice of living with or without a reconstructed breast for many years to come. O

bjective: This article investigates these women’s narratives about the impact of mastectomy on their lives, as well as their reflections on breast reconstruction.

Methods: Fifteen women were strategically chosen from a previous population-based study on mastectomy. They were contacted for further exploration in thematic narrative-inspired interviews 4.5 years after mastectomy.

Results: Three types of storylines were identified. In the first storyline, the mastectomy was described as ‘‘no big deal’’; losing a breast did not disturb the women’s view of themselves as women, and breast reconstruction was not even worth consideration. In the second storyline, the women described the mastectomy as shattering their identity. Losing a breast implied losing oneself as a sexual being, a woman, and a person. The third storyline fell in between the other two; the sense of femininity was wounded, but not to the extent that they felt lost as women.

Conclusion: Our findings suggest that the experience of mastectomy due to breast cancer is very much individual and contextual. Losing a breast may be of minor or major importance.

Implications for Practice: Healthcare practitioners should be attentive to how the women themselves experience the personal meaning of losing a breast and guard against vague preconceptions based on the breast-sexuality-femininity discourse and its connection to what the patient needs.

Sammanfattningsvis identifierades lägre medvetenhet om riskfaktorer för cancer främst  bland dem med lägre utbildning och bland dem i åldersgruppen 50+. Skillnader identifierades även mellan män och kvinnor. Hittills genomförda insatser med syfte att öka kunskapen om  PV verkar otillräckliga(20) och behöver framförallt riktas mot män och grupper med lägre utbildning vilket också bekräftas av andra studier.

Vissa livsstilsrelaterade riskfaktorer för cancer som alkoholkonsumtion, att äta rött- och förbehandlat kött, lågt intag av frukt och grönsaker, och låg fysisk aktivitet var mindre kända hos allmänheten. Eftersom detta är faktorer som den enskilda individen skulle kunna påverka utgör de goda kandidater för preventionskampanjer.

En sammanställning av cancerpreventionsåtgärder i Sverige och deras effekt saknas och vi  efterlyser en sådan. Informationskampanjer höjer oftast den generella kunskapen i samhället men effekten kan vara kortvarig och den självuppfattade risken att drabbas av cancer kan förbli låg.

Våra resultat kan ge en vägledning för att bättre anpassa och rikta information för att nå  lika riskgrupper och höja medvetenhet om cancer.

Prostate cancer and its treatment have long-term implications for men's lives. We aimed to describe the content, extent, and frequency of written comments to the open-ended question, "Further comments?" in the patient-reported outcome measures questionnaire. During the study period, 897 men participated; 372 wrote 747 free-text comments in the questionnaire. These comments were analysed using qualitative content analysis and were grouped into four categories: 1) prostate cancer's influence on health; 2) clarifications of answers to the survey; 3) descriptions of well-being despite the cancer; and 4) experiences of care and the need for contact with health care. The distribution of the comments shifted over time. The open-ended question not only allowed the participants to explain their other responses and describe important aspects of their lives during and after treatment, something not normally covered by a questionnaire, but it also indicated their experiences of health care services along the patients' PC-trajectory. This further raises the issue of including an open-ended item in a forced-choice survey into the ethical realm to ensure that proper care is taken of participants’ answers and thoughts.

AIM: The aim of this study was to further explore expressions of existential experiences by patients diagnosed with malignant melanoma (MM).

METHOD: Semi-structured interviews were performed consecutively after diagnosis among 30 patients with MM. The methodological approach was inspired by Gadamer's hermeneutic philosophy.

RESULTS: The analysis of expressions of existential experiences after having been diagnosed with malignant melanoma revealed that it is an existential process that people go through, beginning with feelings of suddenly becoming groundless at the time of the diagnosis, including being empty and in a vacuum, being in chaos and uncertainty and being confronted with one's own death. Next theme searching for solid ground included striving to understand what lies ahead, striving to find a balance in life - fighting, hoping, going on living and striving to prioritize family. The last theme creating islands of solid ground when living with cancer included understanding what is meaningful in life, living in the moment - seizing the day and keeping watch on the body.

CONCLUSION: On being diagnosed with malignant melanoma, people go through a process where many questions emerge, including an existential turmoil, which health professionals should be aware of to provide these patients with sufficient support.

Objective: To illuminate the meanings of prostate-specific antigen (PSA) testing as narrated by men with localized prostate cancer (LPC) after primary treatment.

Material and methods: Fifteen men were interviewed in their homes. The narrative interview text was analyzed using a phenomenological hermeneutic method inspired by the philosophy of Paul Ricoeur.

Results: Life after treatment for LPC means feeling unsafe because of being affected by a life-threatening and unpredictable disease, characterized by a lack of early signs of progression. In this situation, PSA testing is ascribed as providing a sense of control to enable one to achieve a feeling of safety. Thus one meaning of PSA testing is receiving a message about the status of the body; another is a tense waiting related to fear of the results. A low, stable PSA value is interpreted as a sense of being safe based on confidence in the PSA tests and a sense of having control over the LPC via regular PSA testing. A rising value of the PSA blood test is understood as an indication of progression of the disease, but confidence in PSA testing also means that when the PSA value rises there is a sense of catching the cancer in good time.

Conclusions: The comprehensive understanding of the meaning of PSA testing can be understood in terms of a lifeline to cling to when wondering whether the cancer is still in progress in the body or whether the treatment has been curative. This lifeline creates a feeling of security in a post-treatment life situation which is experienced as being unsafe.

Purpose: The majority of dying patients do not have access to necessary drugs to alleviate their most common symptoms, despite evidence of drug efficacy. Our aim was to explore the degree of consensus about appropriate pharmacological treatment for common symptoms in the last days of life for patients with cancer, among physicians working in specialist palliative care. Material and methods: Within OPCARE9, a European Union seventh framework project aiming to optimize end-of-life cancer care, we conducted a Delphi survey among 135 palliative care clinicians in nine countries. Physicians were initially asked about first and second choice of drugs to alleviate anxiety, dyspnea, nausea and vomiting, pain, respiratory tract secretions (RTS), as well as terminal restlessness. Results: Based on a list of 35 drugs mentioned at least twice in the first round (n = 93), a second Delphi round was performed to determine <= 5 essential drugs for symptom alleviation in the last 48 hours of life that should be available even outside specialist palliative care. There was 80% consensus among the participants (n = 90) regarding morphine, midazolam, and haloperidol as essential drugs. For RTS, there was consensus about use of an antimuscarinic drug, with 9%-27% of the physicians each choosing one of four different drugs. Conclusion: Based on this consensus opinion and other literature, we suggest four drugs that should be made available in all settings caring for dying patients with cancer, to decrease the gap between knowledge and practice: morphine (i.e., an opioid), midazolam (a benzodiazepine), haloperidol (a neuroleptic), and an antimuscarinic.

Advanced prostate cancer with skeletal metastases entails significant symptoms from both treatment and the disease itself. Although the diagnosis is a common one, knowledge of the symptom experience late in the disease trajectory is limited. The aim of the present study was to describe the experience of physical symptoms in men with hormone refractory prostate cancer and skeletal metastases. Twenty men answered a quality of life questionnaire before participating in semi-structured interviews. The interviews were analyzed using qualitative description. Findings show that the dominant symptoms were lack of energy and pain. Interestingly when talking about lacking energy the men described three different variants; lack of mental energy or initiative, lack of strength and stamina, and tiredness or sleepiness. Also, three different types of pain were described; pain from skeletal metastases, a diffuse moving pain, and pain not directly caused by the prostate cancer. Though a majority of the men scored being dissatisfied with their sex life; in the interviews, this was not described as a major distress. The findings also showed that the men experienced different symptoms despite the same diagnosis, skeletal metastases, stage, and androgen deprivation treatment, and that these symptoms are not necessarily experienced as problems or causing distress.

Background: In late-stage palliative cancer care, relief of distress and optimized well-being become primary treatment goals. Great strides have been made in improving and researching pharmacological treatments for symptom relief; however, little systematic knowledge exists about the range of non-pharmacological caregiving activities (NPCAs) staff use in the last days of a patient's life. Methods and Findings: Within a European Commission Seventh Framework Programme project to optimize research and clinical care in the last days of life for patients with cancer, OPCARE9, we used a free-listing technique to identify the variety of NPCAs performed in the last days of life. Palliative care staff at 16 units in nine countries listed in detail NPCAs they performed over several weeks. In total, 914 statements were analyzed in relation to (a) the character of the statement and (b) the recipient of the NPCA. A substantial portion of NPCAs addressed bodily care and contact with patients and family members, with refraining from bodily care also described as a purposeful caregiving activity. Several forms for communication were described; information and advice was at one end of a continuum, and communicating through nonverbal presence and bodily contact at the other. Rituals surrounding death and dying included not only spiritual/religious issues, but also more subtle existential, legal, and professional rituals. An unexpected and hitherto under-researched area of focus was on creating an aesthetic, safe, and pleasing environment, both at home and in institutional care settings. Conclusions: Based on these data, we argue that palliative care in the last days of life is multifaceted, with physical, psychological, social, spiritual, and existential care interwoven in caregiving activities. Providing for fundamental human needs close to death appears complex and sophisticated; it is necessary to better distinguish nuances in such caregiving to acknowledge, respect, and further develop end-of-life care.

Purpose: This study examines whether end-of-life care for patients with cancer who were informed about imminent death differs from care for those patients with cancer who were not informed.

Patients and Methods: This study included all cancer deaths between 2006 and 2008 for which the patient did not lose his or her decision-making capacities until hours or days before death (N=13,818). These patients were taken from a national quality register for end-of-life care. The majority of the patients—91% (n=12,609) —had been given information about imminent death; 9% (n=1,209) had not been informed. Because of the difference in sample size, a matching procedure was performed to minimize bias. This resulted in a comparison of 1,191 informed and 1,191 uniformed patients. Nonparametric methods were used for statistical analyses.

Results: Informed patients significantly more often had parenteral drugs prescribed as needed (ie, PRN), had his or her family informed, died in his or her preferred place, and had family who were offered bereavement support. There was no difference in symptom control (ie, pain, anxiety, confusion, nausea, and respiratory tract secretions) between the groups.

Conclusion: Providing information of imminent death to a patient with cancer at the end of life does not seem to increase pain or anxiety, but it does seem to be associated with improved care and to increase the likelihood of fulfilling the principles of a good death.

More than 70% of seriously ill patients with cancer suffer from xerostomia and the associated problems of swallowing, chewing and speaking. This study aims to investigate whether treatment with acupuncture is a viable option for hospice patients with xerostomia. During a 2-year period, 117 patients were assessed for xerostomia. Eighty-two patients were found to have moderate xerostomia. Sixty-seven fulfilled the criteria for inclusion. Of these, 14 were included but only eight completed the study. Ten acupuncture treatments were given during a 5-week period. The effect of acupuncture was measured using a visual analogue scale, and by measuring the saliva production before and after the series of treatment. The results show that all the patients experienced alleviation of dryness of the mouth and the associated symptoms, and thus benefited from the acupuncture treatment. However, conducting a 5-week acupuncture intervention study is not feasible at an inpatient hospice due to the patients being too close to death.

BACKGROUND: Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff.

METHODS: The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach's alpha on total and on subscale levels; temporal stability was assessed through Pearson's product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit.

RESULTS: The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC.

CONCLUSIONS: POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.

Aim To explore the attitudes held by staff working in acute care units towards patients aged 70 years or older with cognitive impairment, and to explore factors associated with negative attitudes.

Background Hospital staff attitudes towards older patients with cognitive impairment are of concern as older people are the main hospital users, and because staff attitudes influence care quality and uptake of evidence-based care.

Method A cross-sectional survey design was used to collect data from staff (n = 391). Results  Staff attitudes were not explicitly negative. However, higher perceived strain in caring for older patients with cognitive impairment, higher perceived prevalence of these patients in the ward, being younger and working as an assistant nurse were associated with negative attitudes. A majority of staff reported that these patients received the best possible care, but few reported formally assessing cognitive status or working with evidence-based care protocols.

Conclusion Staff characteristics associated with negative attitudes were described and staff perception that patients received best hospital care, despite limited cognitive assessments and care guidelines, indicate areas for improvement. Implications for nursing management Supporting young staff and assistant nurses, and implementing cognitive assessments and evidence-based guidelines can promote positive attitudes and best practice.

AIMS AND OBJECTIVES: To develop a theoretical understanding of the processes hindering person-centred care of older people with cognitive impairment in acute care settings.

BACKGROUND: Although person-centred care with its holistic focus on the biopsychosocial needs of patients is commonly considered the gold standard care for older people with cognitive impairment, the extent to which care is person-centred can increase in acute care settings generally.

DESIGN: Grounded theory inspired by Strauss and Corbin.

METHOD: The study used a grounded theory approach to generate and analyse data from a Swedish sample of acute care staff, patients and family members.

RESULTS: The substantive theory postulates that staff risks 'falling behind' in meeting the needs of older patients with cognitive impairment if working without consensus about the care of these patients, if the organisation is disease-oriented and efficiency-driven, and if the environment is busy and inflexible. This facilitated 'falling behind' in relation to meeting the multifaceted needs of older patients with cognitive impairment and contributed to patient suffering, family exclusion and staff frustration.

CONCLUSIONS: The theory highlights aspects of importance in the provision of person-centred care of older people with cognitive impairment in acute settings and suggests areas to consider in the development of caring environments in which the place, pace and space can meet the needs of the older person.

RELEVANCE TO CLINICAL PRACTICE: The proposed substantive theory can be used to critically examine current ward practices and routines, and the extent to which these support or inhibit high-quality person-centred care for older patients with known or unknown cognitive impairments.

Aim. This study aimed to illuminate meanings of caring for older patients with cognitive impairment in acute care settings as experienced by nursing staff.

Background. Older people with cognitive impairment represent a large group of patients in acute care settings. Research demonstrates that these acute care environments can be unsafe and even unfriendly for frail older patients. Also research and clinical experience reveals that being a nurse in acute/specialized medical facilities means to work in a high-speed, technologically complex and demanding environment. And when providing care for older patients with cognitive impairment, nurses’ workload and responsibilities increases. This being largely dependent on how easily it is to connect with and help patients understand what to do, and what is best for them.

Method. A purposeful sample of thirteen nurses experienced in caring for older people with cognitive impairment in acute care settings participated in the study. Narrative interviews were conducted during autumn 2012 and interpreted using a phenomenological-hermeneutic method.

Findings. Caring for older, acutely ill patients with cognitive impairment was found to be very complex Meanings of caring for older patients with cognitive impairment seemed to shift depending on perception of the patients and the gap between what nurses can do (real) and want to do (ideal) in providing care for these patients. The greater this gap was experienced and the care perceived as meaningless, the more serious the treat to nurses’ personal-professional integrity which could be risked, compromised or harmed.

Comprehensive understanding- Indicates that, being a nurse and having to care for older patients in acute care settings is to provide nursing care in an environment that does not support the nurses’ possibilities to protect and develop their personal–professional integrity.

BACKGROUND: Older people with cognitive impairment represent a large group of patients in acute care settings. Research show that these acute care environments can be unsafe and even unfriendly for frail older patients. Research and clinical experience show that being a nurse in acute/specialised medical facilities means to work in a high-speed, technologically complex and demanding environment. When caring for older patients with cognitive impairment, nurses' workload and responsibilities have been shown to increase. This is largely dependent on how easily it is to connect with and help patients understand what to do, and what is best for them.

AIM: This study aimed to illuminate meanings of caring for older patients with cognitive impairment in acute care settings as experienced by nursing staff.

METHOD: A purposeful sample of thirteen nurses experienced in caring for older people with cognitive impairment in acute care settings participated in the study. Narrative interviews were conducted during autumn 2012 and interpreted using a phenomenological hermeneutic method.

FINDINGS: Caring for older, acutely ill cognitively impaired patients was found to be very complex. The meanings of caring for these older patients seemed to change depending on the nurses' perceptions of the patients and the gap between what they could do (real) and wanted to do (ideal) in providing care for them. The greater this gap was felt to be and the more care was perceived as meaningless, the more serious was the threat to nurses' personal-professional integrity which could be at risk, compromised or harmed.

CONCLUSION: The comprehensive understanding indicates that being a nurse and having to care for older patients in acute care settings means providing nursing care in an environment that does not support possibilities to protect and develop nurses' personal-professional integrity.

Background: Physicians often offer further palliative chemotherapy treatments (PCT) late in the cancer disease trajectory, even when treatment benefits are doubtful.

Objective: Our main aim was to investigate whether routine use of the Performance Status in Palliative Chemotherapy (PSPC) questionnaire would affect the proportions of patients receiving PCT during the last month of life, hospital admissions, documentation of performance status and the decisions to cease PCT, and/or place of death. A secondary aim was to gather registered nurses’ experiences of PSPC in routine use.

Methods: Eighty incurable patients with cancer who had used the PSPC before PCT were compared to 160 matched controls, using non-parametric tests. Patients’ comments in the questionnaires were analyzed and nurses reflections collected in a work-journal.

Results: No significant differences were found between users or non-users of the PSPC in terms of proportions receiving PCT during the last month of life. Higher proportions of patients older than 74 years received PCT than in previous studies (38% versus 17%). Nurses considered the questionnaires superior to verbal communication in providing accurate pictures of patients’ performance status.

Limitations: The results of this interim analysis could have been more significant if the originally planned number of patients had been recruited.

Conclusion: The proportion of patients receiving PCT during the last month of life was lower than in a previous study (25% versus 32%). As we found no significant differences between the study group and the control group, we cannot claim this to be an effect of PSPC use.

BACKGROUND: This study analyses the potential discriminative characteristics for patients with incurable cancer who received palliative chemotherapy during their last month of life.

PATIENTS AND METHODS: The study includes all patients with epithelial cancer treated with palliative chemotherapy who died in 2008 in northern Sweden. Demographic parameters and care utilization data were registered. Data were analyzed using nonparametric methods.

RESULTS: Of 374 included patients, 87 (23%) received chemotherapy during the last month of life. These patients had a significantly shorter survival time from first palliative treatment to death, were admitted more frequently to hospital, more often lacked a documented decision to cease treatment, and died less frequently at home.

CONCLUSIONS: The results indicate covariations between palliative chemotherapy treatments in the last month of life and unfavorable patient outcomes. As almost one of four patients with incurable cancer received their last round of palliative chemotherapy <31 days before death, there is a potential for improved routines.

Palliative chemotherapy treatments (PCT) are becoming more common for patients with incurable cancer; a basic challenge is to optimize tumour response while minimizing side-effects and harm. As registered nurses most often administer PCT, they are most likely to be confronted with difficult situations during PCT administration. This study explores challenging situations experienced by nurses when administering PCT to patients with incurable cancer.

Methods: Registered nurses experienced in administering PCT were asked in interviews to recall PCT situations they found challenging. Inspired by the narrative tradition, stories were elicited and analysed using a structural and thematic narrative analysis.

Results: A total of twenty-eight stories were narrated by seventeen nurses. Twenty of these were dilemmas that could be sorted into three storylines containing one to three dilemmatic situations each. The six dilemmatic situations broadly related to three interwoven areas: the uncertainty of the outcome when giving potent drugs to vulnerable patients; the difficulty of resisting giving PCT to patients who want it; and insufficient communication between nurses and physician.

Conclusion: Nurses who administer PCT are engaged in a complex task that can give rise to a number of dilemmatic situations. The findings may be interpreted as meaning that at least some situations might be preventable if the knowledge and insight of all team members – nurses, physicians, patients, and relatives – are jointly communicated and taken into account when deciding whether or not to give PCT. Forming palliative care teams early in the PCT trajectory, could be beneficial for staff and patients.

Research shows slow improvement of the care of dying persons and their significant others. One of the reasons for that is the lack of palliative care education as an integral part of health professionals' undergraduate education. The paper discusses an attempt to develop innovative forms of palliative care education: an international, interprofessional and IT-supported undergraduate course for Swedish and Slovenian students of nursing, medicine, occupational therapy, physiotherapy, psychology and social work, which has been developed jointly by the two authors. One of the aims of the course has been to address differences in professional and national cultures relevant to quality in palliative care. The development and pilot implementation phases of the course were analysed qualitatively, using evaluation materials from students and teachers and from an external evaluation study. The results show that the interprofessional approach in the course enabled students to get to know other professions, as well as enabling them to work together as a team and resolve conflicts. Cultural differences between Sweden and Slovenia were not very pronounced, yet they came to the fore regarding teamwork and relationships between professions, as well as in respect of the “right thing” to do in relation to patient' problems.

PURPOSE OF REVIEW: The trajectory of living with incurable cancer is characterized by increasing deterioration of the person's body. The aim of this review is to gain insight into the expert knowledge people have about their own lived experiences of bodily deterioration and symptoms in late palliative phases of cancer, and suggest a framework for understanding and studying these experiences. RECENT FINDINGS: When assessing the presence, severity and distress of symptoms and problems experienced by patients, it is important to carefully consider choice of instruments, which by nature, tend to target distinct problems, and expand assessment to include narrative approaches. Deterioration of the body and symptom distress can have dire consequences for the individuals, as these threaten the intactness of the person, may lead to desire to end one's life, can act as determinant of place of death, and dominate the sick person's existence. SUMMARY: Understanding the meaning bodily deterioration and symptoms have for patients is intrinsic for optimization of supportive interventions. We suggest that improved integration of knowledge from logical scientific and narrative approaches in research aiming to generate empirical and/or theoretical knowledge, and cross-fertilization of research from closely related areas can contribute to improving care for this vulnerable group of patients.

As revealed in previous empirical research, nurses describe their position in home-based nursing care (HBNC) as that of guests' in the patient's home. Such a description is problematic as guests' might not be considered to belong to the realm of professionalism. As Jacques Derrida's work on hospitality has received wide publicity, sparking theoretical and philosophical discussion about host and guest, the aim of this study was to explore how the concept guests' can be understood in the light of Derrida's philosophy of hospitality. The study revealed that (a) guest must be considered a binary concept; and (b) hospitality should be regarded as an exchange of giving and receiving between a host and a guest. The present study demonstrated that it is important to reflect on the meaning of the concepts used by nurses in HBNC. Further theoretical and empirical exploration of the concept hospitality' would be fruitful, i.e. what is patients' understanding of hospitality' and hostility' related to nurses' descriptions of themselves as guests' in the patient's home.