Expectations of elderly people on the nurse-client relationship and interaction in home care : "When I see the nurse's smiling face it feels likes sunshine on a rainy and gloomy day"

The purpose of the thesis was to explore expectations of elderly people on the nurse-client relationship and interaction in home care. The aim is to improve the quality of care to better meet the needs of the clients. A qualitative approach was adopted. Semi-structured theme interviews were used for data collection. The interviews were conducted during spring 2006. Six elderly clients of a private home care company in Southern Finland acted as informants. Content analysis was used as the method of data analysis. The findings suggest that clients expect nurses to provide professional care with loving-kindness. Trust and mutual, active interaction were expected from the nurse-client relationship. Clients considered it important that the nurse recognizes each client's individual needs. The nurse was expected to perform duties efficiently, but in a calm and unrushed manner. A mechanic performance of tasks was considered negative. Humanity was viewed as a crucial element in the nurse-client relationship. Clients expressed their need to be seen as human beings. Seeing beyond the illness was considered important. A smiling nurse was described to be able to alleviate pain and anxiety. Clients hoped to have a close relationship with the nurse. The development of a close relationship was considered to be more likely if the nurse is familiar and genuine. Clients wish the nurses to have a more attending presence. Clients suggested that the work areas of the nurses could be limited so that they would have more time to transfer from one place to another. Clients felt that they would benefit from this as well. The nurses were expected to be more considerate. Clients wished for more information regarding changes that affect their care. They wished to be informed about changes in schedules and plans. Clients hoped for continuity from the nurse-client relationship. Considering the expectations of clients promotes client satisfaction. Home care providers have an opportunity to reflect their own care behaviour on the findings. To better meet the needs of the clients, nurses could apply the concept of loving-kindness in their work, and strive for a more attending presence.

Private Home Care in Municipal Service Systems – A Case Study among Finnish and Swedish Municipalities

The aim of this study is to assess the current and future preconditions for conducting private business in municipal service systems for home care in Lahti and Hyvinkää in Finland, and in Uppsala and Huddinge in Sweden. This study also aims to assess the implications of quality related issues on the preconditions for conducting private business in the service systems in question. The theories and the research methodologies of the study are based on the Business Model Generation and the Business Model Canvas -concepts. Also a couple of frameworks on implications of quality are applied and integrated into the study. The study is completed as a case study – with structured and identical approaches for all four municipalities. The analyses and assessments of the study are primarily qualitative, but supported by simple quantitative methodologies. The data of the study consists primarily of publicly available information, and secondarily of answers provided by the case-municipalities to multiple choice questions. The results of the study show that the service systems for home care among the case-municipalities are, from perspective of private companies, diverse with local characteristics. Both the premises for conducting private business and the quality-issues are in many respects different in the Finnish and the Swedish case-municipalities. This is partly due to differences in the national service systems; the service voucher system versus the system of choice. Still, it appears that the current preconditions for conducting private business in the service systems for home care, including the implications of quality, would be more favorable in Uppsala and Huddinge than in Lahti and Hyvinkää. On the other hand, the service systems are subject to changes, and the most positive and significant development is here forecasted for a Finnish case-municipality (Lahti). Communication of quality is clearly more advanced in the Swedish case-municipalities. The results of this study can be utilized in several ways, for instance by private companies interested in entering into service systems for home care, either in some of the case-municipalities, or in some other Finnish or Swedish municipalities. Also municipalities can apply the analyses of the study when designing, developing or evaluating their own service systems for home care.

Supporting older people’s independent living at home through social and health care collaboration

Tässä tutkimuksessa tarkasteltiin ikäihmisten kotona asumista sosiaali- ja terveydenhuollon yhteistyön näkökulmasta. Tutkimuksen tarkoituksena oli lisätä ymmärrystä iäkkäiden kotihoidon asiakkaiden voimavaroista arjesta selviytymisen näkökulmasta, ja tutkia miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutuu. Tutkimus oli poikkileikkaustutkimus, jossa sovellettiin kuvailevaa ja vertailevaa tutkimusasetelmaa. Tutkimusaineisto kerättiin yhden länsisuomalaisen kunnan kotihoidon asiakkailta (≥65 v.) ja heitä hoitavilta ammattihenkilöiltä. Kotihoidon 21 iäkästä asiakasta kuvasivat omia voimavarojaan arjesta selviytymisen näkökulmasta sekä kokemuksiaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin avoimella haastattelulla ja analysoitiin sisällön analyysillä. Lisäksi 25 kotihoidon ammattihenkilöä: 13 kotipalvelun työntekijää, 11 kotisairaanhoitajaa ja lääkäri kuvasivat kokemuksiaan iäkkään asiakkaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin fokusryhmähaastattelulla ja analysoitiin sisällön analyysillä. Näiden tulosten sekä aikaisemman kirjallisuuden perusteella laadittiin strukturoitu kyselylomake, jolla analysoitiin ja vertailtiin asiakkaiden ja ammattihenkilöiden näkemyksiä siitä, miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutui. Esitestausten jälkeen kyselylomake lähetettiin 200 kotihoidon asiakkaalle ja 570 heitä hoitavalle kotihoidon työntekijälle: 485 kotipalvelun työntekijälle, 81 kotisairaanhoitajalle ja 4 lääkärille. Kyselyyn vastasi 120 asiakasta (60 %) ja 370 ammattihenkilöä (65 %). Ryhmien välisten erojen tarkastelussa käytettiin ristiintaulukointia, Pearsonin khin neliötestiä ja Fisherin tarkan todennäköisyyden testiä. Iäkkäiden asiakkaiden kuvauksissa voimavarat muodostuivat elämänhallinnan tunteesta ja toimintatahdon säilymisestä. Asiakkaat ammensivat arkeen voimaa harrastuksista ja sosiaalisesta verkostosta, mutta ulkopuolisten asettamat elämisen ehdot, terveydentilan heikkeneminen sekä yksinäisyys asettivat ikäihmisen ja hänen voimavaransa suurten haasteiden eteen. Tulokset osoittivat, että ammattihenkilöiden toiminta oli osittain ristiriidassa ikäihmisten omien odotusten kanssa, eikä se kaikilta osin tukenut asiakkaiden omia voimavaroja. Ammattihenkilöt tekivät hoitoon liittyviä päätöksiä ja toimintoja asiakkaiden puolesta, vaikka asiakkaille itselleen oli tärkeää elämänhallinnan tunne ja toimintatahdon säilyminen. Asiakkaiden voimavarojen tukemista moniammatillisena yhteistyönä vaikeuttivat ammattihenkilöiden vaikeus tunnistaa asiakkaiden omia voimavaroja sekä niitä uhkaavia tekijöitä, tiedon kulun ongelmat, tavoitteeton ja epäyhtenäinen tapa toimia sekä ammattihenkilöiden vastakkain asettuvat näkemyserot ja toimintatavat. Asiakkaiden ja ammattihenkilöiden näkemykset toteutetusta hoidosta erosivat toisistaan tilastollisesti merkitsevästi (p<0.05). Asiakkaat arvioivat sekä itsenäiseen toimintaan tukemisen että fyysisen, psyykkisen ja sosiaalisen tuen toteutuneen työntekijöitä huonommin. Yhteistyön kehittämishaasteita kotihoidossa ovat asiakkaan oman elämänsä asiantuntijuuden vahvistaminen, toimintakulttuurin muuttaminen asiakaslähtöiseksi tavoitteelliseksi toiminnaksi, ammattihenkilöiden roolien ja vastuun selkiyttäminen sekä tiedon kulun menetelmien kehittäminen. Tutkimus vahvistaa gerontologisen hoitotieteen tietoperustaa ja tuottaa uutta tietoa, jota voidaan soveltaa sosiaali- ja terveysalan koulutuksessa ja johtamisessa

Configuring Health Care Services - Service Control Improvement

The costs of health care are increasing, and at the same time, population is aging. This leads health care organizations to focus more on home based care services. This thesis focuses on the home care organization of the South Karelian District of Social and Health Services (Eksote), which was established in 2010; how its operation is organized and managed, and which problem types are faced in the daily operation of home care. This thesis examines home care services through an extensive interview study, process mapping and statistical data analysis. To be able to understand the nature of services and special environment theory models, such as service management and performance measurement, service processes and service design are introduced. This study is conducted from an external researcher‟s point of view and should be used as a discussion opener. The outcome of this thesis is an upper level development path for Eksote home care. The organization should evaluate and build a service offering, then productize home care services and modularize the products and identify similarities. Service processes should be mapped to generate efficiency for repeating tasks. Units should be reasonably sized and geographically located to facilitate management and operation. All this can be done by recognizing the different types of service products: runners repeaters and strangers. Furthermore, the organization should not hide behind medical issues and should understand the legislative, medical and operational frameworks in health care.

Distribution channel plan for wound care products: Case 3M Finland Ltd.

The aim of this master’s thesis was to make a qualitative marketing research and on the basis of this to develop a distribution plan for the case company Finnish 3M Ltd.’s wound care products. The literature review includes three important parts: distribution channel planning, the buying behavior of seniors, and special characteristics of health care products’ marketing. The empirical part of this thesis comprises two different parts. The first part is a marketing research, in which the buying behavior of wound care products is studied in Espoo. The research aim was to examine, in which distribution channels the wound care patients under home care would most preferably buy wound care products during the time period, when municipalities will not yet provide the products for free. The data was collected through semi-structured phone interviews and regular interviews, and was treated qualitatively and anonymously. The study revealed that the recommendations of nurses and doctors influenced most the buying behavior of wound care customers. In the second part of the thesis a distribution channel plan for wound care products was made for the case company 3M Finland Ltd. based on the results. 3M Finland Ltd. should focus on pharmacies, online-stores and municipal health centers as their main distributors.

International nursing : cultivating a culture of empowerment

International nursing has been a growing phenomenon throughout the globe. International nurses have been found to be an asset to healthcare organizations and an important part of the health care team. However, growing concern for the plight of international nurses facing obstacles such as professional stagnation and exploitation has spurred the development of strategies to mitigate and ameliorate the experiences of nurses working abroad. In this respect, the purpose of this study was to explore the management-influenced factors and the nurse team-influenced factors that promote the empowerment of the international nurse in the health care setting. The methodology used in this study was a systemic review. After a rigorous search for relevant empirical studies using OVID database, eight empirical research studies were selected using systematic review methodology to collect, analyze and synthesize data. The selected eight empirical studies were then subjected to a content analysis. The results suggested that the empowerment of an international nurse is inseparable from the empowerment of the health care organization. Based on the findings in this study, strategies to promote international nurses were found to mirror strategies evidenced to empower the nursing organization. Some of the management-influenced factors which were found to facilitate empowerment included a diversity rich work culture, transformational leadership at the management level, and a responsibility to foster the values of the organization. The team-influenced factors which were found to contribute to the empowerment of the international nurse included a united mutually-interdependent nurse team, shared accountability among the members of the nurse team, and the building of trust in work relationships. To conlude, this study indicates that efforts to empower international nurses without considering the work culture and the organization as a whole are futile because empowerment cannot take place in an environment that lacks antecedent conditions. Strategies to empower the international nurse should not focus on the deficits and special needs of the international nurse, but should focus on the similarities and commonalities of the nursing body. Empowerment of the international nurse mean open honest communication, supportive work environment, and a firm policy to quell disruptive elements that threaten the organization's values, mission, and philosophy of care.

Kotihoidon sisältö ja laatu vanhusasiakkaiden, omaisten ja työntekijöiden arvioimana : seurantatutkimus Kuopion kotihoidosta

Summary: Content and quality of home care - perceptions of the elderly, their relatives and home care staff. The follow-up study in Kuopio

Asiakkaiden avun tarpeen ja auttamisen vastaavuus kotihoidossa

Abstract: The correspondence between clients' needs and assistance in home care

Osuuskunta hyvinvointipalvelujen vaihtoehtoisena tuottajana

The purpose of this thesis is to describe the meaning of cooperation for the entrepreneurs who have planned to establish a co-operative. The objective is to understand what kind of benefits, expectations and challenges entrepreneurs see in the co-operative business and its establishment. The context of the study is welfare sector. As the population ages, increases the need for welfare services and the role of private service providers emphasizes. The study is based on qualitative theme interview. The empirical material was collected by interviewing eleven entrepreneurs in home care and home nursing sectors. The interviews were executed during the summer and autumn 2006. As an additional material there have been used five interviews of entrepreneurs who are members of co-operatives in different sectors. These interviews were executed during the spring 2007. The results show that the entrepreneurs experience that cooperation brings noticeable added value to their business activity. Cooperation is believed to be a channel to develop business activities. Besides development, co-operative business is expected to reply to the collective needs of entrepreneurs. The biggest challenges of functional cooperation are opportunistic behavior and finding a trustworthy group of entrepreneurs to establish the co-operative. Successful cooperation with the public sector would be the mutual benefit of government, companies and clients.

The Future of Mobile Services and Wireless Applications in the Finnish Healthcare Sector

Työn päätavoitteena oli tutkia mobiilipalveluita ja langattomia sovelluksia Suomen terveydenhuollon sektorilla. Tutkimus havainnollistaa avain-alueita, missä mobiilipalvelut ja langattomat sovellukset voivat antaa lisäarvoa perinteiseen lääketieteen harjoittamiseen, ja selvittää, mitkä ovat tähän kehitykseen liittyvät suurimmat ongelmat ja uhkat sekä tutkimustuloksiin pohjautuvat mahdolliset palvelut ja sovellukset 5-10 vuoden kuluttua. Tutkimus oli luonteeltaan kvalitatiivinen ja tutkimuksen toteuttamiseen valittiin tulevaisuudentutkimus ja erityisesti yksi sen menetelmistä, delfoi-menetelmä. Tutkimuksen aineisto kerättiin kahdelta puolistrukturoidulta haastattelukierrokselta. Työn empiirinen osuus keskittyi kuvailemaan Suomen terveydenhuollon sektoria, siinä meneillään olevia projekteja sekä teknisiä esteitä. Lisäksi pyrittiin vastaamaan tutkimuksen pääkysymykseen. Tutkimustulokset osoittivat, että tärkeät alueet, joihin langaton kommunikaatio tulisi vaikuttamaan merkittävästi, ovat ensiaputoiminta, kroonisten potilaiden etämonitorointi, välineiden kehittäminen langattomaan kommunikaatioon kotihoidon parantamiseksi ja uusien toimintamallien luomiseksi sekä lääketieteellinen yhteistyö jakamalla terveydenhuoltoon liittyvät informaation lähteet. Työn tulosten perusteellavoitiin antaa myös muutamia toimenpide-ehdotuksia jatkotutkimuksia varten.

Vanhusten hyvä kotona asuminen: tutkimusta kuntatuottavuudesta, älykodeista ja apuvälinepalveluprosesseista

The purpose of the research was to investigate operational processes related to home care of the elderly as well as use of assistive devices in smart home environments, and operational processes that are generally related to use of assistive devices – from the point of view of productivity improvement. The themes were looked into from the points of view of both the elderly and care personnel. In addition, perspectives of near relatives of the elderly, of the larger service system as well as of companies that provided assistive devices to the smart homes were taken into consideration. In the study of home care processes, 32 customer interviews and 17 employee interviews were carried out. This report contains a summary that is based on a separate report of the home care study. The study of home care was conducted in 2006. The use of technological and mechanical assistive devices and the related operational processes were investigated with the help of the smart home pilot in 2007–2008. The study is described in this report. The smart home pilot was implemented in four different housing service units for elderly people at Lahti, Nastola and Hollola. They were in use during short-term housing periods related to, for instance, end of hospitalisation, holidays of caring relatives and assessment of living and housing conditions. More than 60 different assistive devices and technologies were brought to the smart homes. During the pilot period, experiences of customers and personnel as well as processes related to the use of assistive devices were investigated. The research material consisted of 20 survey questionnaires of personnel and customers, four interviews with customers, five interviews with personnel, feedback survey responses from 14 companies, and other data that were collected, for instance, in orientation events. The research results highlighted the need for tailored services based on an elderly person’s needs and wishes, while taking advantage of innovative and technological solutions. As in the earlier home care study, also assistive device-related operational processes were looked into with the help of concepts of ‘resource focus’, ‘lost motion’ and ‘intermediate landing’. The following were identified as central operational processes in assistive device-related services (regardless of the service provider): (1) acquisition process of technologies and assistive devices as well as of rearrangement and rebuilding works in the home, (2) introduction and orientation process (of the elderly, their relatives and care personnel), (3) information and communication process, and (4) service and monitoring process. In addition, the research focused on design and desirability of assistive devices as well as their costs, such as opportunity costs. The process-based points of view gave new knowledge that may be used in the future to develop service processes and clarify their ownership so that separately managed cross-functional processes could be built with participants from different sectors to operate alongside organisations of elderly care. Development of functionality of assistive device-related services is a societally significant issue.

A practice perspective on organizational implementation of information technology

Implementering av ett informationssystem ur en organisatorisk synvinkel initieras av en idé om ett system och avslutas då användningen av det inte längre kräver en medveten ansträngning. Ifall tolkningen av implementering är denna, är det fråga om en långsam och komplicerad process, som berör organisationens alla parter. Ny informationsteknologi anses påverka flertalet arbetsprocesser och organiseringen av det dagliga arbetet. Möjligheterna att ta i bruk systemet och utnyttja det är många. I avhandlingen undersöks implementering av ett system för att administrera hemvårdsbesök där hemvårdare använde handdatorer för att registrera information om besökens längd och innehåll. I avhandlingen observeras vilka förändringar som sker i arbetets praxis p.g.a. det nya systemet och hur dessa förändringar påverkar vårdarbetet. Forskningen inleds med att strukturera teorier om arbetspraxis för kommande analys. Arbetspraxis är inarbetade och rutinmässiga arbetssätt i arbetets sociomateriella omgivning. Arbetspraxis i avhandlingen innebär hemvårdarens praxis och upplevd erfarenhet, där verksamheten informeras av gemensamma arbetssätt, projekt, identiteter och intressen. Organisationens auktoritet kommer även fram i den förverkligade arbetspraxisen. Forskningen genomfördes som en etnografisk longitudinell studie under åren 2001-2004. I studien observerades hur nyttjandet av handdatorerna framskred ur ett organisatoriskt perspektiv. Hemvårdares arbete och verksamhet (arbetspraxis) observerades både under vårdsbesök och under pauser. Därtill intervjuades hemvårdarna för att erhålla en bättre förståelse för de rationaliteter som styr arbetet och hur systemet togs i bruk. Dokument relaterade till projektet att införa ett nytt system och administrativa dokument har utnyttjats som källmaterial. Analysen av källmaterialet styrdes av det teoretiska tillvägagångssättet att undersöka arbetspraxis. Problem som identifierades i samband med införandet av systemet och de förändringar som det medförde analyserades i detalj. Parallellt analyserades organisatorisk makt, kontroll och arbetsidentitet. Undersökningen beskriver hur det nya systemet gradvis anpassades till hemvården efter ett initialt motstånd. Under själva implementering av systemet ifrågasattes tidigare arbetspraxis och inställningen till den eftersom arbetspraxisens materiella omgivning förändrades. Det teoretiska tillvägagångssättet i att undersöka arbetspraxis framhäver vårdarens agerande i förändringsprocessen. Resultatet av forskningen visar vikten av realistiska målsättningar, givande av gruppstöd med återkoppling samt förmåga att anpassa sig till det oväntade vid införande av informationssystem.

Foot Health In Older People - Development of a preventive, evaluative instrument for nurses

Foot health is a part of overall health in every age group and its importance increases during ageing. Health care professionals are in a vital position for preventing foot health problems, and identifying and caring them in older people. Despite the rather high number of studies conducted in the field of foot health in older people, reliable and valid nurse-administered foot health assessment instruments seem to be lacking. By identifying foot health in older people, it is possible to develop nursing interventions to enhance safe, independent living at home. The purpose of this three-phase study was to develop an instrument to assess the level of foot health in older people and evaluate foot care practices from the perspective of older people themselves and nurses in home care. The ultimate goal is to prevent foot health problems by increasing the attention paid to older people’s feet and recognizing those foot health problems which need further care; thus not focus on different foot health problems. The study was conducted in different phases and contexts. In phase 1, a descriptive design with a literature review from the Medline (R) and CINAHL databases to explore foot health in older people and nurses’ role in foot health care and pre-post design intervention study in nursing home with nursing staff (n=16) and older residents (n=43) were conducted. In phase 2, a descriptive and explorative study design was employed to develop an instrument for assessing foot health in older people (N=651, n=309, response rate 47%) and explore the psychometrics of the instrument. The data were collected from sheltered housing and home care settings. Finally, in phase 3, descriptive and explorative as well as cross-sectional correlational survey designs were used to assess foot health and evaluate the foot self-care activities of older people (N=651, n=309, response rate 47%) and to describe foot care knowledge and caring activities of nurses (N=651, n=322, response rate 50%) in home care in Finland. To achieve this, the Foot Health Assessment Instrument (FHAI) developed in phase 2 was used; at the same time, this large sample also was used for the psychometric evaluation of the FHAI. The data analysis methods used in this study were content analysis, descriptive and inferential statistics including factor and multivariate analysis. Many long-term diseases can manifest in feet. Therefore, the FHAI, developed in this study consisted of items relating to skin and nail health, foot structure and foot pain. The FHAI demonstrated acceptable preliminary psychometric properties. A great deal of different foot health problems in older people were found of which edema, dry skin, thickened and discoloured toenails and hallux valgus were the most prevalent foot health problems. Moreover, many older people had difficulties in performing foot self-care. Nurses’ knowledge of foot care was insufficient and revealed a need for more information and continuing education in matters relating to foot care in older people. Instead, nurses’ foot care activities were mainly adequate, though the findings indicate the need for updating foot care activities to correspond with the evidence found in the field of foot care. Practical implications are presented for nursing practice, education and administration. In future, research should focus on developing interventions for older people and nurses to promote foot health in older people and to prevent foot health problems, as well as for further development of the FHAI.

Simuloinnin hyödyntäminen kotihoidon kehittämisessä

Ikääntyvien ihmisten kasvava määrä tulevina vuosikymmeninä kuormittaa kaupunkien kotihoitoa enenemässä määrin. Kaupunkien rajalliset resurssit ovat jo nyt koetuksella, eikä nykyiseen tilanteeseen ole nähtävissä huomattavaa parannusta tulevina vuosina. Kotihoidon henkilöstön määrää ei pystytä kasvattamaan riittävästi suhteessa kasvavien asiakasvirtojen kanssa, jotta korkea palvelun laatu voitaisiin taata myös tulevaisuudessa. Lahden kaupungin kotihoito pyrkii etsimään teknisiä ratkaisuja kotihoidon haasteisiin muun muassa kotihoidon töiden jakamiseen kehitetyllä optimointialgoritmilla sekä simuloinnilla. Tämä diplomityö käsittelee toimintatutkimuksen avulla simuloinnin tuomia hyötyjä sekä rajoitteita Lahden kotihoidon näkökulmasta. Launeen alueen kotihoidon haasteita käydään läpi neljässä eri työpajassa. Työssä esitetään Quest-simulointiohjelmiston ominaisuuksia, sekä Launeen alueen simulointimallin luomista aina suunnittelusta verifiointiin. Työn tuottama lisäarvo kotihoidon kehittämisessä tulee ilmi neljässä eri vaihtoehtoajossa kotihoitajien asiakkaalta toiselle kulkemien matkojen ja matkoihin käytettyjen aikojen mittaamisessa.