Sense of meaning in life among the oldest old people living in a rural area in northern Sweden.

BACKGROUND: Having meaning in life is important for all people, and according to Erikson's developmental theory, this is especially true for older adults. However, there are few studies about meaning in life focusing on the oldest old. AIM: The aim of our study was to illuminate the sense of meaning in life in the oldest old living in northern Sweden. DESIGN: The study has a qualitative explorative and interpretative design. METHOD: We interviewed three men and seven women between 85 and 95 years old and analysed the interviews using qualitative content analysis. FINDINGS: Our findings revealed the following four themes: 'Creating space for living', 'Living in connection with others and nature', 'Seeing oneself as a link between generations' and 'Having trust in God'. CONCLUSIONS: The sense of meaning in life in the oldest old was linked to regarding oneself as having a mission to carry out and to finding beauty, joy and happiness in life. The sense of meaning involved transferring to coming generations what earlier generations had left and having a deeply rooted faith in being taken care of from birth to the afterlife. IMPLICATIONS FOR PRACTICE: When caring for the oldest old, it is important to take their experiences of sense of meaning in life into consideration and to focus on ways to maintain important sources of meaning in life.

Being a preceptor-a Nordic qualitative study.

BACKGROUND: Positive preceptor experiences enhance learning and even affect the decisions of students to remain in nursing. In light of this, nurse managers have a responsibility, besides maintaining staff competence, to assess whether preceptors live up to their professional obligations. AIM: The aim of this Nordic qualitative study was to gain a deeper understanding of the perceived experiences of preceptorship used to support undergraduate student nurses during their clinical education. METHOD: Data was collected through narrative interviews with 31 preceptors in Finland and Sweden before being analysed using a hermeneutical approach. FINDINGS: Preceptorship is all about teaching in a supportive environment with ethical dimensions uniting theory and praxis. A caring relationship is essential and the basis for student learning and development. CONCLUSION: The preceptors emphasise a caring relationship as the foundation for student learning. Moreover, preceptorship is an ethical issue, a responsibility that should be recognised by all stakeholders. The findings suggest that preceptorship should be examined from a new perspective. The ethical dimension must be recognised and linked to the further education of preceptors. Nurse managers are in a key position to lead for change.

Perspectives on good preceptorship: A matter of ethics.

BACKGROUND: Clinical education is an essential part of the Bachelor's program in Nursing and a keystone of professional nursing education. Through clinical experiences, the student nurses acquire nursing knowledge and essential skills for professional practice. The preceptor plays a vital role in the development of student nurses becoming professional nurses. AIM: The aim of this Nordic qualitative study was to explore the experiences of good preceptorship in relation to undergraduate student nurses in clinical education from the perspective of the preceptors themselves. METHOD: Data were collected by narrative interviews with 27 preceptors in Finland and Sweden and analyzed using a hermeneutical approach. FINDINGS: A caring relationship, based on caring ethics, is seen as the foundation for learning and development. Moreover, a mutual respect is a prerequisite for fellowship and a good atmosphere. As such, encounters are characterized by reciprocity and mutuality. The preceptors have a deep sense of responsibility toward the students and the profession. Furthermore, the preceptors have an inner responsibility to guide the students into working life and to share their knowledge by acting as role models. CONCLUSION: The findings suggest that preceptorship should be examined through new lenses. Moreover, preceptorship is an ethical issue that should be recognized by all stakeholders.

Inner strength as a mediator of the relationship between disease and self-rated health among old people.

AIM: To explore inner strength as a mediator of the relationship between disease and self-rated health among older people. BACKGROUND: Qualitative research has indicated that inner strength is an essential resource for an individual affected by disease. A hypothesis of inner strength as a mediator of the relationship between disease and self-rated health was proposed. The theoretical framework of inner strength was based on the Model of Inner Strength. DESIGN: A cross-sectional design was used. METHOD: The sample included 6119 participants from Finland and Sweden, in the ages of 65, 70, 75 and 80 years. The GERDA-Botnia questionnaire, which included the Inner Strength Scale and items related to diseases and self-rated health, was sent out between October and December 2010. Structural equation modelling was used to test a hypothesized model. RESULTS: The result indicated that having a disease was associated with poorer self-rated health and a lower degree of inner strength and a higher degree of inner strength was associated with better self-rated health. The result supported the hypothesis by indicating that inner strength partially mediated the relationship between disease and self-rated health. CONCLUSION: This large cross-sectional study with participants from 65 to 80 years of age from Finland and Sweden showed that inner strength can be a resource for older people affected by disease. Increasing inner strength in older people affected by disease may be one intervention to support experiences of health despite disease.

Inner strength in relation to age, gender and culture among old people--a cross-sectional population study in two Nordic countries.

OBJECTIVES: The theoretical framework for the study was the Model of Inner Strength, and the Inner Strength Scale (ISS)developed based on the Model was used. The aim was to examine inner strength in relation to age, gender and culture among old people in Sweden and Finland. METHOD: This study forms part of the GErontological Regional DAtabase (GERDA)-Botnia project that investigates healthy ageing with focus on the dignity, social participation and health of old people. The participants (N = 6119) were 65-, 70-, 75- and 80-year old and living in two counties in Sweden or Finland. The ISS consists of 20 items relating to four interrelated dimensions of inner strength, according to the Model of Inner Strength. The range of possible ISS scores is 20-120, a higher score denoting higher inner strength. RESULT: The result showed that the 65-year-old participants had the highest mean ISS score, with a decrease in score for every subsequent age. The lowest score was achieved by the 80-year-old participants. Women had slightly but significantly higher mean ISS scores than men. Only small differences were found between the counties. CONCLUSION: The study population came from Sweden and Finland; still, despite the different backgrounds, patterns in the distribution of inner strength were largely similar. The present study provides basic and essential information about inner strength in a population of old people.

Quality of clinical education--comparison of experiences of undergraduate student nurses in Finland and Sweden.

The purpose of this study was to compare the experiences of three groups of undergraduate student nurses on the quality of clinical education over time. The study is part of a longitudinal research and development project in Finland and Sweden. The sample (n = 109) consisted of three subgroups of student nurses: the first in a Swedish faculty (SWE) (n = 53), the second in a Finnish faculty (FIN1, n = 42), and the third in another Finnish faculty (FIN2, n = 14). In the comparison of the subgroups, FIN1 and FIN2 were put together, because of the small sample size. The first data was collected in 2009 after the students' first clinical education period in acute and elderly care. The second data was collected in 2010 after the students' second clinical education period on different wards in central hospitals, in primary care units and in elderly care. The data was collected using a self-administered questionnaire and analysed using statistical methods. On the basis of an explorative factor analysis conducted on the first data four sum variables were produced, named as follows: Clinical Preception, Learning in Clinical Education, Learning Objectives in Clinical Education, and Reflection in Clinical Education. In the comparison of the years 2009 and 2010 (n = 109), the factors Clinical Preception and Learning Objectives in Clinical Education had lower evaluations in year 2010 than in year 2009. In year 2009 Swedish students (n = 53) evaluated Clinical Preception and Learning in Clinical Education lower than Finnish students (n = 56). In year 2010 Finnish students evaluated Clinical Preception lower than Swedish students. It is evident that the clinical education practices should be developed in cooperation with the faculties and the staff of the clinical education placements.

Psychometric properties of the Swedish version of the selection, optimization, compensation questionnaire.

BACKGROUND: The model of selection, optimization and compensation has been proposed as a model of adaptive management strategies throughout the lifespan. AIM: The aim of this study was to test the psychometric properties of a translated Swedish version of the 12-item selection, optimization, and compensation (SOC) questionnaire. METHOD: The 12-item SOC questionnaire is composed of four subscales: elective selection (ES), loss-based selection, optimization and compensation. A convenience sample of 122 Swedish-speaking people, aged 19-85, participated in a study of the validity and reliability of the SOC questionnaire. Cronbach's alpha coefficient, corrected item-total correlation and Cronbach's alpha if item deleted were used for reliability testing. Two other scales, the ways of coping questionnaire and Rosenberg's self-esteem scale, were used to test convergent validity, and the geriatric depression scale was used to test discriminant validity. Stability over time was evaluated using a test-retest model with a 2-week interval. RESULTS: The 12-item SOC questionnaire showed a Cronbach's alpha value of 0.50, and the subscales ranged from α = 0.16 to α = 0.64. Two items in the ES subscale had negative values on the corrected item-total correlation and showed substantial improvement (>0.05) in Cronbach's alpha when item deleted. When these two items that influenced internal consistency were deleted, Cronbach's alpha rose to 0.68. CONCLUSION: The Swedish version of the 12-item SOC questionnaire showed deficiencies in a test of internal consistency because of two items in the ES subscale, and these two items were deleted. A consequence of the reduction is a weakening of the ES subscale and thereby to some extent the SOC questionnaire in total. Further testing is advisable. However, the 10-item SOC questionnaire was acceptable in a test of validity and reliability.

Changes in sense of coherence in old age - a 5-year follow-up of the Umeå 85+ study.

OBJECTIVE: This study aims to describe the changes in sense of coherence (SOC) over time and relate these changes to negative life events among very old people. DESIGN: Prospective and longitudinal study. SUBJECTS: 190 old women and men participated, of whom 56 could be included in the 5-year follow-up. METHODS: The mean SOC score from the first and second data collection were compared using a paired sample t-test. The relationship between the index of negative life events and the changes on SOC score between the two data collections was investigate using linear regression. MAIN OUTCOME MEASURES: Antonovsky's SOC scale and an index of negative life events including severe physical and mental diseases, various losses as losses of spouses, cognitive and functional ability. RESULT: For the whole group of subjects (n = 56), the SOC scores was higher (70.1 vs. 73.7, p = 0.029) at the second point measure. The most common negative life events at follow-up were loss of independence in activities in daily living and decrease in cognitive function. A significant correlation between the index of negative life events and changes in SOC over 5 years was found (p = 0.025). The more negative life events, the more decrease in SOC. CONCLUSION: We concluded that there is a risk of decreased SOC and thereby quality of life when negative life events accumulate among very old people. Nursing interventions might play an important role for maintaining and perhaps strengthening SOC among old people exposed to negative life events.

Finnish and Swedish nursing students' experiences of their first clinical practice placement--a qualitative study.

BACKGROUND: Nursing is a practice-based discipline. Clinical practice settings are important in preparing undergraduate nursing students for the role of registered nurse. AIM: The aim of this Nordic qualitative study is to illuminate first year undergraduate nursing students' experiences of clinical practice during their first clinical placement, with a focus on preception, reflection, and the link between theory and practice. METHOD: Data were collected by focus group interviews with 22 nursing students, and analyzed with qualitative content analysis. FINDINGS: Positive experiences included stimulating and visible preceptors, a permissive atmosphere, and reflection as a matter of course. Negative experiences were related to feelings of abandonment and powerlessness when preceptors were invisible and the atmosphere at the ward was non-permissive. The implementation of research-based knowledge was insufficient. CONCLUSIONS: A permissive atmosphere and visible preceptors are crucial if learning is to be maximized. Consequently, it is important to set aside time for preceptors to be more visible and to make the atmosphere at the clinical placement more permissive. The student must have the opportunity to combine scientific knowledge with evidence-based knowledge in order to develop nursing actions.

Inner strength in relation to functional status, disease, living arrangements, and social relationships among people aged 85 years and older.

Inner strength is described as an important resource that promotes well-being. We used data from a sample of 185 people in the Umeå 85+ cohort study to relate inner strength and its attributes to objective health variables. The Resilience, Sense of Coherence, Purpose in Life, and Self-Transcendence scales were used to assess aspects of inner strength, and strong correlations between the scales were found. Prevalence of heart failure, chronic obstructive pulmonary disorder, osteoporosis, or diagnosed depression was associated with low inner strength. Significant relationships were also found between high inner strength and various measures of social relationships. Participants with a higher degree of inner strength had better physical health and more satisfying social relationships. The promotion of inner strength should be a major aim of geriatric nursing.

Development and psychometric properties of the Inner Strength Scale.

BACKGROUND: Four dimensions of inner strength were previously identified in a meta-theoretical analysis: firmness, creativity, connectedness, and flexibility. OBJECTIVE: The aim of this study was to develop an Inner Strength Scale (ISS) based on those four dimensions and to evaluate its psychometric properties. METHOD: An initial version of ISS was distributed for validation purpose with the Rosenberg Self-Esteem Scale, the resilience scale, and the sense of Coherence Scale. A convenience sample of 391 adults, aged 19-90 years participated. Principal component analysis (PCA) and confirmatory factor analysis (CFA) were used in the process of exploring, evaluating, and reducing the 63-item ISS to the 20-item ISS. Cronbach's alpha and test-retest were used to measure reliability. RESULTS: CFA showed satisfactory goodness-of-fit for the 20-item ISS. The analysis supported a fourfactor solution explaining 51% of the variance. Cronbach's alpha on the 20-item ISS was 0.86, and the test-retest showed stability over time (r=0.79). CONCLUSION: The ISS was found to be a valid and reliable instrument for capturing a multifaceted understanding of inner strength. Further tests of psychometric properties of the ISS will be performed in forthcoming studies.

Sense of coherence (SOC) related to health and mortality among the very old: the Umeå 85+ study.

We describe associations between sense of coherence (SOC) and sense of well-being, diseases, physical function and the predictive value of SOC on depression and mortality. The study included 190 participants, aged 85-103 years. Linear correlation analysis was used for relationships between SOC scores and continuous variables. The effects of SOC score on 1- and 4-year mortality, as well as on depression at the 5-year follow-up, were investigated using Cox regression models. The mean SOC score was 71.8±10.2 (±S.D.). SOC score was positively related to well-being (p≤0.001). Heart failure (p=0.009), chronic obstructive pulmonary disease (p=0.015), depression (p=0.015), and osteoarthritis (p=0.032) were significantly associated with low SOC scores, as were high scores on the Geriatric Depression Scale (GDS) (p=0.002). One-year mortality was significantly associated with the SOC score (OR=0.945, confidence interval (CI)=0.898-0.995, p=0.032), while the 4-year mortality was not (OR=0.995, CI=0.973-1.018, p=0.674). The SOC score did not predict depression at 5-year follow-up (OR=0.977, CI=0.937-1.018, p=0.267). Strong SOC was associated with well-being in this group of old people. Low SOC was found among those with diseases known to have a negative influence on daily life.

Psychometric properties of the Swedish version of the Purpose in Life scale.

The aim of this study was to test the theoretical assumptions beyond the Purpose in Life (PIL) scale, and to elucidate the underlying structure of the Swedish version of the PIL. The PIL, originally created by Crumbaugh and Maholick, is a 20-item scale of the Lickert type with possible scores ranges from 20 to 140, the higher score, the stronger PIL. The analysis was based on 449 participants, 62% of whom were women, from five different samples, ranging from 19 to 103 years old. An exploratory factor analysis restricted to three factors was performed. The factors were labelled meaning in existence, freedom to create meaning in daily life, and will to find meaning in future challenges. These factors reflected the three dimensions described by Frankl. Cronbach's alpha coefficient for the total scale was 0.83 and varied between 0.54 and 0.83 in the three factors. We concluded that the Swedish version of the PIL scale seems to have construct validity and reliability. Our results give support to the fact that the PIL scale captures and confirms the theoretical assumptions of Frankl's existential theory. We consider the PIL scale to be both feasible and appropriate for use in nursing research.

Inner strength--a theoretical analysis of salutogenic concepts.

BACKGROUND: Theoretical and empirical overlaps between the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence have earlier been described as some kind of inner strength, but no studies have been found that focus on what attributes these concepts have in common. OBJECTIVES: The objective of this study was to perform a theoretical analysis of the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence, in order to identify their core dimensions in an attempt to get an overarching understanding of inner strength. PRINT METHOD: An analysis inspired by the procedure of meta-theory construction was performed. The main questions underlying the development of the concepts, the major paradigms and the most prominent assumptions, the critical attributes and the characteristics of the various concepts were identified. RESULTS: The analysis resulted in the identification of four core dimensions of inner strength and the understanding that inner strength relies on the interaction of these dimensions: connectedness, firmness, flexibility, and creativity. These dimensions were validated through comparison with the original descriptions of the concepts. CONCLUSION: An overarching understanding of inner strength is that it means both to stand steady, to be firm, with both feet on the ground and to be connected to; family, friends, society, nature and spiritual dimensions and to be able to transcend. Having inner strength is to be creative and stretchable, which is to believe in own possibilities to act and to make choices and influence life's trajectory in a perceived meaningful direction. Inner strength is to shoulder responsibility for oneself and others, to endure and deal with difficulties and adversities. This knowledge about inner strength will raise the awareness of the concept and, in turn, hopefully increase our potential to support people's inner strength.

Vision and hearing impairments and their associations with falling and loss of instrumental activities in daily living in acute hospitalized older persons in five Nordic hospitals.

BACKGROUND: Many older people believe sensory problems are inevitably, a part of growing old, and avoid assessment and help. Such problems are often also overlooked by health professionals. The aim of this study was to find the prevalence of hearing and vision impairment and their associations with loss of instrumental activities in daily living (IADL) and risk of falling in patients aged 75 years or older, admitted to a medical ward in an acute hospital in each of the five Nordic countries. METHOD: The Minimum Data Set for Acute Care was used for data collection in 770 patients. Premorbid data, admission data and history of falls over 3 months were obtained on admission by interview and observation. Hearing impairment was present if the patient required a quiet setting to be able to hear normal speech. Vision impairment was defined as unable to read regular print in a newspaper. RESULTS: Bivariate and logistic regression analyses were performed. Forty-eight per cent of the patients had a hearing impairment, 32.3% had vision impairment and 20.1% had both. Hearing impairment was associated with falling but not in the logistic regression model. Hearing and vision impairment were associated with loss of IADL but only combined impairment was independently. CONCLUSION: Hearing and vision impairments were frequent among older patients in the medical wards. Falling was associated with hearing loss and IADL loss with hearing, vision and combined impairments. Sensory loss was also associated with fear of falling. It is recommended routinely to screen sensory functions in older patients in a medical setting. Intervention studies are needed to determine whether improvements in hearing and vision can prevent falls and further loss of function in this patient population.

Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment.

AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. METHOD: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. FINDINGS: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases. CONCLUSIONS: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.

Admission profile is predictive of outcome in acute hospital care.

BACKGROUND AND AIMS: The purpose of this study is to describe predictors for discharge and one-year outcomes of acute-care hospital patients, 75 years of age or over, based on admission status information. We carried out a prospective study of a randomly selected patient population, from one urban acute-care hospital in each of the Nordic countries. 763 persons aged 75+ were randomly selected from acute admissions to the participating hospitals. 749 observations at discharge and 655 observations at one year were used in analyses. METHODS: Data were collected with the MDS-AC 1.1 instrument within 24 hours of admission, and at day 7 or discharge, whichever came first. Outcome information was collected either by interviewing the patient or from patient records or registers. Discharge and one-year outcome (home, institution, death) were modeled by multinomial logistic regression, with admission status variables as predictors. RESULTS: At discharge, 84% of subjects returned home, 11% went to an institution and 5.6% had died. At one year, 64% were still living at home, 24% had died, and 12% had moved to an institution. For discharge outcome, those having hospital admission due to a new problem or exacerbation of an old one had a higher risk of dying (OR 3.3) than returning home. Moderate to severe cognitive problems predicted death (OR 2.2) and institutionalization (OR 8.6) compared with discharge home. Problems in instrumental activities of daily living predicted death (OR 3.1) and institutionalization (OR 6.0). At one year, those with exacerbation of an old problem (OR 2.1) or with a new or exacerbated existing problem (OR 2.3) had a higher risk of dying than of institutionalization or discharge home. Having some cognitive problems (OR 2.8) or moderate to severe cognitive problems (OR 6.6) predicted institutionalization, but not dying or discharge home. Those with some problems in activities of daily living had a higher risk of both dying (OR 1.7) and of institutional care (OR 2.7). Those with moderate to severe problems in activities of daily living had also a higher risk of institutional care (OR 4.7) compared with those living at home. CONCLUSIONS: Evidence predictive of discharge and one-year outcomes in older acute hospital medical care patients seems to be visible from the beginning of the hospital stay. In order to increase the efficient use of health care services and quality of care, systematic standardized and streamlined assessment should be performed during the admission process.