Features of Swedish municipal elderly and psychiatric group dwelling care after the health-care reforms of the 1990s

Sammanfattning: The over all aim of this thesis, consisting of six studies, was to explore features of the Swedish municipal elderly and psychiatric group dwelling care after the 1990s health care reformation era. Focus is primarily on the municipal psychiatry. The mixed design, used here, employs both quantitative and qualitative methods. In paper I all psychiatric municipal care providers' caring approaches towards a fictitious elderly long-term client with schizophrenia was explored through a questionnaire. Approximately 70 per cent of the nurses had a symptom-orientated approach which focuses on correction of disease-related symptoms towards the clients. If the nurses had been working for less than 10 years they tend to have a more person-centred approach, which indicate that long- term job experience might affect the care providers' attitudes towards the clients negatively. In paper II the existence of a visible pattern in care providers' attitudes and their arguments for the preferred approaches towards a fictitious elderly person (Mrs NN) with a diagnosis of long term schizophrenia was investigated. Fourty-eight (73%) of the respondents (n = 66) emphasized the importance of meeting Mrs NN within the framework of reality and the need as a care provider to focus on the present or the 'here and now' when they communicate with her. Twenty-seven per cent stressed the importance of meeting Mrs NN within the framework of a person-focused approach to the same question. The majority was unable to see the client a as anything else than what the diagnosis said. The purpose of paper III was to investigate twenty care providers' experiences of job satisfaction, whose work involves taking care of clients suffering from dementia and elements of ' aggressiveness' and 'psychomotor agitation'. The individual narrative interviews indicated exposure, insufficiency, a feeling of not being valued and doubt, as well as respect and importance and devotion towards the residents. The interpretation of the narrations showed that an ambiguous and complex core-theme: 'job satisfaction as a process moving between breaking down and occasionally building up the working person'. The care providers experienced that they only got support from each other and the positive relationship with colleagues was mentioned as the primary reason for care providers' continuing to work at the group dwellings. The organisation and resident behaviours were seen as very negative. Just a small degree of support was experienced from the side of the organisation. In paper IV the aim was to investigate how clients at two psychiatric group dwellings spend their time using the Patient Activity Classification (PAC). The clients who displayed a predominant picture of negative symptoms were left alone for 84% of the day. Of this 29.5% could be explained by their illness. The results indicated that, even if the dwellings had a creative climate, there was a negative process in terms of care providers' well-being with a moderate degree of emotional exhaustion, depersonalisation, and personal accomplishment. In paper V the aim was to investigate the connections between the time spent together and the care providers' opinion of client behaviour and social functioning in community-based psychiatry. Twenty nine clients' were assessed by 30 care providers, who answered the Global Assessment of Functioning Scale (GAF) and the Positive and Negative Syndrome Scale (PANSS). The PAC instrument revealed that clients spent, an average of 60.8 per cent of time alone, while only 20 per cent of their daily time was spent with the care providers. Four groups of clients were created based on the GAF scores, high and low, and a PANSS scores, high and low, related factor analysis. The clients in the group judged as having a low level of social functioning in combination with high degrees of psychiatric symptoms, receive less staff attention (18%) and are the clients who spend the most time alone (73.4%). Finally, in paper VI, the professional role of care providers in social psychiatry is in the midst of a period of role re-definition towards a recovery, client-focused perspective. In three focus group interviews 13 care providers discussed their views and experiences of their professional role at a social PGD (Psychiatric Group Dwelling) context when caring for clients suffering from severe mental illness. Thematic content analysis was conducted. Four themes were formulated: 'Being a general human factotum not unlike the role of parents', 'Having a complex and ambiguous view of clients', 'Working in a mainly "strangled" situation', and 'Feeling overwhelming frustration'.The findings showed that when aspects of the care were related to Kari Martinsen's ontological theory of care, including a practical, relational- and moral dimension, the moral dimension seemed to cause the care providers suffering. Furthermore, a figure is presented to illuminate how the findings contributing to different levels of the features of municipal EGD (Elderly Group Dwelling) and PGD care can be understood and related to each other. There is a hope that the results of this research could be used as a foundation to develop educational- and "contact" programs for care providers and others with the interpretation and the power to decide. This might, in a longer perspective, lead to a positive development for all identified levels, with special focus on a higher degree of experienced quality of life for both elderly and psychiatric clients.

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