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Aim: To construct and evaluate psychometric properties of the person-centred care of older people with cognitive impairment in acute care settings (POPAC) scale.

Background: Older people with cognitive impairment are admitted frequently to acute care, with needs not always met through standard practice. Best practice models have been suggested, but few assessment scales exist.

Methods: Psychometric evaluation using statistical estimates of validity and reliability based on an Australian sample of acute care nursing staff (n = 212).

Results: The final 15-item questionnaire consists of three subscales, using cognitive assessments and care interventions, using evidence and cognitive expertise and individualizing care. Estimates of validity and reliability were highly satisfactory.

Conclusion: The POPAC scale makes a valuable contribution by providing valid and reliable measures of the extent to which acute nursing staff report using best practice care processes to identify and consider cognitive impairment and to employ nursing interventions to meet the needs associated with old age and cognitive impairment.

Implications for nursing management: The POPAC scale is short, easy to administer and not time consuming to complete, but still provides clinically relevant information. It can be used as a conceptual fundament in developing best practice nursing care in the acute clinical setting, as well as for nursing research.

The influence of a person-centred psychosocial unit climate on satisfaction with care and work Aim To describe nurses satisfaction with care and work and to explore the extent to which a person-centred unit climate influenced this satisfaction. Background Although the concept of person-centred care is used to describe high-quality care, there is a shortage of studies exploring the relationship between person-centredness and nurses satisfaction with care and work in acute care settings. Methods Registered nurses within a university hospital in Sweden (n = 206) completed the Satisfaction with Nursing Care and Work Assessment Scale and the Person-centred Climate Questionnaire. The data collected was analysed using descriptive and analytical statistics. Design Cross-sectional explorative study. Results The majority of respondents were satisfied with the care and work situation. Nurses with more than 9 years of work experience were more satisfied with care and work, and there were a significant association between a person-centred psychosocial climate of units and nurses satisfaction with care and work. Conclusions This study provided evidence for a significant association between person-centredness and the satisfaction with care and work of nurses in acute care environments. Implications for nursing management Promoting and implementing a person-centred philosophy of care can be one way to improve nurses satisfaction with care and work.

Inledning: Äldre personer med kognitiv svikt, exempelvis i form av demenssjukdom, delirium eller depression, är en vanligt förekommande population inom svensk sjukhusvård. Dessa äldre kan ha särskilda behov till följd av en försämrad kognition, men litteraturen tyder på att akutsjukhusens miljö, organisation och vårdprocesser inte alltid stödjer tillgodoseendet av dessa behov.

Syfte: Det övergripande syftet med avhandlingen var att belysa vården av äldre personer med kognitiv svikt i sjukhusmiljöer.

Metoder: Avhandlingen består av fyra delstudie. I studie I tillämpades en tvärsnittsdesign för att utforska personalens attityder till äldre patienter med kognitiv svikt, personalens tillfredsställelse med vården och arbetet samt upplevelsen av personcentrerat vårdklimat (n=391). I studie II användes en Grounded theory design för att undersöka hinder för personcentrerad vård för äldre personer med kognitiv svikt på en akutmedicinsk vårdavdelning. I studie III tillämpades en tvärsnittsdesign för att utforska de psykometriska egenskaperna i den svenska versionen av ”The Person-centred care of Older People with cognitive impairment in Acute Care scale” (POPAC) i ett urval av sjukhuspersonal (n=293). I studie IV användes en fenomenologisk hermeneutisk design för att belysa innebörder av att vårda äldre patienter med kognitiv svikt på akuta sjukvårdavdelningar utifrån vårdpersonals (n=13) berättelser.

Resultat: Studie I visade att deltagande personal skattade en neutral attityd till äldre patienter med kognitiv svikt i spektret mellan negativa och positiva attityder, samt att faktorer som att vara yngre, undersköterska och att uppleva vården av de äldre som betungande, hade samband med mer negativa attityder. Resultaten visade också att vårdpersonal upplevde att äldre patienters kognition sällan utvärderades under vårdtiden, samt att man sällan baserade vården på evidensbaserade riktlinjer för vård av äldre med kognitiv svikt. Studie II belyste att ett organisatoriskt fokus på medicinska behov, åtgärder och rutiner bidrog till att personal hamnade steget efter i relation till att synliggöra och möta dessa äldre personers multidimensionella behov, och att detta kunde medföra tecken på vårdlidande för de äldre, utanförskap för närstående och frustration för personal. Studie III stödde en fortsatt användning av POPAC-skalan för skattningar av upplevd förekomst av personcentrerade vårdprocesser för äldre patienter med kognitiv svikt, men att ytterligare studier rekommenderades framförallt av skalans olika dimensioner. Studie IV belyste att ju större avstånd som upplevs mellan vad vårdpersonalen kan göra (verklig vård) och vad de vill göra (ideal vård) för äldre patienter med kognitiv svikt i akuta vårdmiljöer, desto meningslösare upplevs vården, och desto större blir hotet mot personalens personlig-professionella integritet. Den tolkade helheten visar på att vårda äldre patienter med kognitiv svikt inom akutsjukvård betyder att försöka ge omvårdnad i miljöer som inte stödjer vårdpersonalens personlig-professionella integritet

Slutsatser: En rimlig konklusion av dessa resultat är att det i sjukhusmiljöer där äldre patienter ofta vårdas kan finnas anledning att diskutera och ytterligare studera hur attityder, synsätt på och målsättningar för vården och dess innehåll, åtgärder och interventioner kan främja eller motverka en god omvårdnad för de äldre med kognitiv svikt. Det kan också finnas anledning att se över hur personalen kan stödjas i att ge person-centrerad vård till de äldre, exempelvis genom riktlinjer för vård av äldre personer med kognitiv svikt, standardiserade skattningar av kognition, samt implementering av vårdprocesser som stödjer en personcentrerad vård för dessa patienter. Det kan också finnas behov av att ytterligare kritiskt granska hur organisatoriska och miljömässiga faktorer på avdelningar stödjer eller motverkar en personcentrerad vård för äldre patienter med kognitiv svikt. Därtill kan det finnas behov av att skapa ytterligare förutsättningar för vårdpersonalen att bevara och utveckla sin personlig-professionella integritet genom att utveckla miljöer som ger möjligheter för dem att ge en god omvårdnad till dessa äldre.

AIM AND OBJECTIVES: To describe nurses' experiences of providing person-centred care for older people on an acute medical ward.

BACKGROUND: There is evidence that person-centred care for older people contributes to a higher quality care and increased satisfaction with care. However, there is a shortness of studies providing concrete examples of what facilitates nurses providing person-centred care for older people in acute care.

DESIGN: An interview study with qualitative content analysis. COREQ guidelines have been applied.

METHOD: Fourteen registered nurses and enrolled nurses from an acute care ward participated in semi structured research interviews. The interviews were conducted during 2016 and interpreted using qualitative content analyses.

RESULTS: Person-centred care was described at different levels in care; at the individual nurse level, person-centred care was described as involving person-centred assessing, relating and spacing which involved personalising assessments, relationships as well as the physical environment. At the team level, person-centred care was described in terms of person-centred goal setting, team responsibilities and team support, and involved having shared and personalised goals, different team responsibilities and a climate of support and collaboration. At the organisational level, person-centred care was described in terms of having person-centred routines, workloads and staff roles that all contributed to put the person at the core of the organisation and build routines to support this.

CONCLUSIONS: The current study emphasises that, rather than confining person-centred care to specific moments or relationships, a systematic, multilevel organisational approach seems needed to enable nurses as individuals and teams to provide person-centred care consistently and continuously to older people in acute care settings.

RELEVANCE TO CLINICAL PRACTICE: The results of this study should inspire nurses and managers to expedite implementation of person-centred care for older care recipients hospitalised in acute care wards. Examples of person-centred care are presented herein at clearly identified sites, namely, the "individual," "team" and "organisational levels."

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.

The aim of this analysis was to examine the concept of time to rejuvenate and extend existing narratives of time within the nursing literature. In particular, we hope to promote a new trajectory in nursing research and practice which focuses on time and person-centred care, specifically of older people with cognitive impairment hospitalized in the acute care setting. We consider the explanatory power of concepts such as clock time, process time, fast care, slow care and time debt for elucidating the relationship between 'good care' and 'time use'. We conclude by offering two additional concepts of time, plurotemporality and person-centred time (PCT) which we propose will help advance of nursing knowledge and practice. Nurse clinicians and researchers can use these alternative concepts of time to explore and describe different temporal structures that honour the patient's values and preferences using experiential, observation-based nursing research approaches.