The overall aim of the thesis was to explore healthcare professionals’ and volunteers’ experiences of encountering older persons’ existential loneliness, the significance of the care context, and first-line managers’ view of support. Three of the studies were qualitative with a descriptive design (studies I–III) and the fourth was quantitative with a cross-sectional design (Study IV). The data collection for studies I and II was based on focus group interviews with healthcare professionals (i.e., nurse assistant, registered nurse, physician, occupational therapist, physiotherapist, social counsellor, and social worker) in home care, residential care, hospital care, palliative care, primary care, and pre-hospital care. The data collection for Study III was based on focus group interviews and individual interviews with volunteers from various organisations. Study IV was based on a questionnaire sent to first-line managers in municipal care, examining their views of support for staff and volunteers encountering existential issues among older persons.   The findings of Study I indicated that, during the everyday care of older people, healthcare professionals experienced existential loneliness in various ways and situations related to ageing, illness, and end of life. The professionals’ stories about encountering older persons’ existential loneliness revealed that they often felt insecure about how to talk about existential issues. They also felt inadequate and frustrated when encountering barriers such as the older person’s bodily limitations, demands and needs (perceived as insatiable), personal privacy, or fear and difficulty in encountering existential issues. Study II was a multiple case study of the care contexts of home care, residential care, hospital care, and palliative care. The findings indicated that the care context matters regarding professionals’ views and interpretations of the origin of existential loneliness. In home care and residential care, these views and interpretations concerned life, the present, and the past. In hospital and palliative care, existential loneliness mainly concerned the older person’s forthcoming death. Professionals considered creating relationships an important part of their role in all care contexts, although the meanings, purposes, and conditions of these relationships differed (Study II). Study III showed that being a volunteer meant being a fellow human being, alleviating others’ and one’s own loneliness. Becoming a volunteer was 11  12 a way of finding meaning, and volunteering made the volunteers feel rewarded and simultaneously emotionally challenged. Encountering loneliness, including existential loneliness, required sensitivity to others’ needs for both closeness and distance. The findings of Study IV, based on a questionnaire, indicated that 88% of the first-line managers found that older persons sometimes or often expressed existential loneliness. They also reported that staff insecurity was the major obstacle to talking about existential issues with the older persons. Support was provided in the form of structured reflection, but provision of systematic supervision was reported by only 6% of first-line managers. The managers reported that most support was provided by themselves or by registered nurses. Almost half of the managers (44%) reported that, at their units, volunteers were engaged in activities such as everyday conversations and/or music/entertainment. In addition, they also reported a desire for volunteers to be more involved in both everyday and existential conversations. In conclusion, one of the most important findings of this thesis was the insecurity of the professionals, manifested in a fear of discussing existential issues. This was revealed in the interviews with the professionals and confirmed by the first-line managers. According to both professionals and volunteers, the relationship with the older person was important when encountering existential issues. The thesis demonstrates the importance of helping professionals focus on existential issues about life and death and of the potential of volunteers as an important complement in the care of older people.

BACKGROUND: The increasing proportion of older people worldwide is challenging society and the healthcare sector to develop new solutions, such as involving volunteers, especially to combat loneliness among older people. Loneliness is a broad concept comprising, for example existential loneliness - a deep feeling of aloneness in the world. We know little about volunteers' experience of encountering older people's loneliness in general and existential loneliness in particular. Such knowledge is important in order to develop high-quality volunteering.

AIM: This study aimed to describe volunteers' experience of becoming and being a volunteer, and encountering older people's loneliness in general and existential loneliness in particular.

METHODS: This descriptive qualitative study is based on eight focus group interviews and twelve individual interviews with volunteers from different organisations, analysed using conventional content analysis.

FINDINGS: Being a volunteer meant being a fellow human being, alleviating loneliness for others and oneself. Becoming a volunteer was a way of finding meaning, and volunteering made the volunteers feel rewarded and simultaneously emotionally challenged. Being a volunteer also meant acting on one's values, challenging boundaries when necessary. Encountering loneliness, including existential loneliness, required sensitivity to others' needs for both closeness and distance.

CONCLUSION: Being a volunteer benefitted not only the older persons the volunteers met, but also the volunteers' own sense of meaning, by alleviating their own loneliness. Sharing existential thoughts and having meaningful conversations about life and death are challenging, but can contribute to the personal growth of the volunteers themselves. It is important to remember that not all volunteers are confident in having existential conversations, so it is important to pay attention to each volunteer's prerequisites and needs. In addition, there is a need for support to volunteers' engagement such as clarifying their role and clarifying the responsibility and expectations from health and social care.

AIM:

To explore existential loneliness among older people in different healthcare contexts from the perspective of healthcare professionals.

BACKGROUND:

Professionals meet and care for older people in most care contexts and need to be prepared to address physical, psychological, social and existential needs. Addressing existential loneliness can be both challenging and meaningful for professionals and is often not prioritised in times of austerity.

DESIGN:

A multiple case study design was used.

METHODS:

Focus group interviews were conducted with healthcare professionals (n = 52) in home, residential, hospital and palliative care settings. The analysis was performed in two steps: firstly, a within-case analysis of each context was conducted, followed by a cross-case analysis.

FINDINGS:

Differences and similarities were observed among the care contexts, including for the origin of existential loneliness. In home care and residential care, the focus was on life, the present and the past, compared to hospital and palliative care, in which existential loneliness mainly related to the forthcoming death. The older person's home, as the place where home care or palliative care was received, helped preserve the older person's identity. In hospital and palliative care, as in institutional care, the place offered security, while in residential care, the place could make older people feel like strangers. Creating relationships was considered an important part of the professionals' role in all four care contexts, although this had different meanings, purposes and conditions.

CONCLUSIONS:

The context of care matters and influences how professionals view existential loneliness among older people and the opportunities they have to address existential loneliness.

IMPLICATIONS FOR PRACTICE:

Support for professionals must be tailored to their needs, their education levels and the context of care. Professionals need training and appropriate qualifications to address existential loneliness related to existential aspects of ageing and care.

Objective: A recent project to develop Health and Social Care Plannings in Collaboration (HSCPC) resulted in a new model for care plannings in older persons’ homes. After having used the model for about six months, the management and participating professionals asked researchers for support to evaluate the model. In particular they wanted to know how the older persons experienced the HSCPC and how the model could be improved.

Methodology: We used a Participatory Action Research approach and invited older persons, their relatives and professionals who had participated in HSCPC. The older persons and their relatives were interviewed individually two weeks after the HSCPC and the profes- sionals from the same care planning took part in focus groups. The professionals and the management were also invited to participate in feedback sessions.

Results: Older persons, relatives and professionals expressed an overall positive attitude to HSCPC. In particular they appreciated that the meeting was held in the older persons’ homes and that the older persons were able to express their own experiences and wishes. Preparation of the meeting, communications skills during the meeting and follow up’s were areas that should be improved. During the feed- back sessions, professionals and management came up with ideas of how to handle improvement needs.

Conclusion: The initial development project became an established part of everyday practice characterized by an endeavor to make continuous improvements. Thus, it could be viewed as a triple-helix project.

När en person är medicinskt färdigbehandlad på sjukhuset och ska skrivas ut, men i fortsatt behov av vård och omsorg sker en övergripande vårdplanering på sjukhuset för att fördela ansvaret mellan kommun och landsting/region, en så kallad Samordnad vårdplanering (SVPL). Det handlar om att fördela ansvaret både praktiskt och ekonomiskt samt att besluta om vem som ansvarar för uppföljning. När vården och omsorgen ges i det egna hemmet beviljas personen insatser via hemsjukvården och då bör en specifik vårdplan upprättas (Region Skåne, 2005). Dokumentet benämns vård- och omsorgsplan i samverkan (VOPS) eftersom vårdplaneringen skall ske i samverkan mellan kommunens och primärvårdens personal. Denna VOPS skall vara framåtsyftande till sin karaktär och verka för att bevara den enskildes hälsa och välbefinnande i ett längre perspektiv, där också personens egna önskemål tas med i planeringen. En avsikt är också att en VOPS-planering skall följa personen i hela processen, kommunen, primärvården och specialistvården. Genom dokumentationen skall sedan olika vårdgivare kunna skapa sig en uppfattning om personens situation och de olika vårdbehov som finns och kan uppstå för att ge en god vård och omsorg. En annan avsikt är också att förebygga oplanerade sjukhusinläggningar genom att planera åtgärder vid akut insjuknande och försämring. I den här studien har tio VOPS-möten följts upp med individuella intervjuer med den äldre och dennes närstående samt fokusgruppsintervjuer med personalgruppen. Avsikten har varit att fånga olika deltagares erfarenheter av att delta i och genomföra en vård- och omsorgsplanering i samverkan (VOPS).

PURPOSE: Existential loneliness is part of being human that is little understood in health care, but, to provide good care to their older patients, professionals need to be able to meet their existential concerns. The aim of this study was to explore health care professionals' experiences of their encounters with older people they perceive to experience existential loneliness.

METHOD: We conducted 11 focus groups with 61 health professionals working in home care, nursing home care, palliative care, primary care, hospital care, or pre-hospital care. Our deductive-inductive analytical approach used a theoretical framework based on the work of Emmy van Deurzen in the deductive phase and an interpretative approach in the inductive phase.

RESULTS: The results show that professionals perceived existential loneliness to appear in various forms associated with barriers in their encounters, such as the older people's bodily limitations, demands and needs perceived as insatiable, personal shield of privacy, or fear and difficulty in encountering existential issues.

CONCLUSION: Encountering existential loneliness affected the professionals and their feelings in various ways, but they generally found the experience both challenging and meaningful.

Providing health and social care to older persons is challenging, since older persons often have multiple diseases and a complex health situation. Hence many professions and organisations are involved. Lack of interprofessional and interorganisational collaboration leads to fragmented care. Care planning meetings before hospital discharge have long been used to overcome this fragmentation, but meetings conducted at the hospital have limitations in identifying long-term needs at home. A new model for health and social care planning in collaboration (HSCPC) in older persons' homes was introduced in two Swedish municipalities. The aim of this study was to gain a deeper understanding of the HSCPC-meeting from the perspectives of older persons, family members, and professionals. Ten care planning meetings from two municipalities were consecutively included. Interviews in retrospect with ten older persons, eight family members, and ten groups of professionals who had attended the HSCPC-meeting at home were analysed with a hermeneutic approach. Four themes emerged: unspoken agendas and unpreparedness, security and enhanced understanding, asymmetric relationships, and ambiguity about the mission and need for follow-up. The comprehensive interpretation is that the professionals handled the HSCPC-meeting mainly as a routine task, while the older persons and family members viewed it as part of their life course. Older persons are in an inferior institutional, cognitive and existential position. However, meeting together in the home partly reduced their inferior position. Findings from this study provide some general suggestions for how HSCPC-meetings should be designed and developed: attention of power relations, the importance of meeting skills and follow-up.