ARTICLE IN PRESS
International Journal of Nursing Studies 44 (2007) 71–82
www.elsevier.com/locate/ijnurstu
Work situation of registered nurses in municipal elderly care in
Sweden: A questionnaire survey
Karin Josefssona,b,c,, Lars Sondeb,c, Bengt Winbladc,
Tarja-Brita Robins Wahlinb,c
a
Department of Health Sciences, Örebro University, S-701 82 Örebro, Sweden
KC-Kompetenscentrum, Research and Development Centre in Elderly Care, Sweden
c
Department of Neurobiology, Caring Sciences and Society, Karolinska Institutet, Sweden
b
Received 13 July 2005; received in revised form 21 September 2005; accepted 10 October 2005
Abstract
Background: Organizational changes have occurred in municipal elderly care in Sweden during the past decades. The
‘Ädel’ reform transferred responsibility for the care of older persons from the county councils to the municipalities.
Furthermore, the specialisation in dementia care divided elderly care into two groups: dementia and general care. This
change has had a significant impact on the work situation of registered nurses (RNs).
Aim: The main focus was to describe RNs’ work situation and their characteristics in municipal elderly care. Another
aim was to compare RNs working solely in dementia care with those working in general care of older persons with
diverse diagnoses.
Design: A non-experimental, descriptive design with a survey research approach was used.
Settings: Sixty special housing units with underlying units including those offering daytime activities in a large city in
the middle of Sweden.
Participants: The number of participating RNs was a total of 213, with a response rate of 62.3%. Of the 213 RNs, 95
(44.6%) worked in dementia care, and 118 (55.4%) in general care.
Method: A questionnaire survey.
Results: The results indicated high levels of time pressure in both groups. Greater knowledge and greater emotional
and conflicting demands were found in dementia care. The majority perceived a greater opportunity to plan and
perform daily work tasks than to influence the work situation in a wider context. Support at work was perceived as
generally high from management and fellow workers and higher in dementia care.
Conclusion: It is important to decrease RNs’ time pressure and increase their influence on decisions made at work.
r 2005 Elsevier Ltd. All rights reserved.
Keywords: Registered nurses; Municipal elderly care; Work situation; Demand-control model
What is already known about the topic?
Corresponding author. Department of Health Sciences,
Örebro University, S-701 82 Örebro, Sweden.
E-mail address: [email protected] (K. Josefsson).
There
0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2005.10.014
is a paucity of extensive description of
registered nurses’ work situation and their characteristics in municipal elderly care in Sweden.
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K. Josefsson et al. / International Journal of Nursing Studies 44 (2007) 71–82
72
What this paper adds
Results
indicated high levels of time pressure in
dementia and general care. Greater knowledge and
greater emotional and conflicting demands were
found in dementia care.
The majority perceived a greater opportunity to plan
and perform daily work tasks than to influence the
work situation in a wider context.
Support at work was perceived as generally high
from management and fellow workers and higher in
dementia care.
1. Introduction
In 1992 the ‘Ädel’ reform was introduced for the care
of older persons in Sweden (National Board of Health
and Welfare, 1996). This dramatic restructuring of
elderly care transferred the responsibility for the care
of older persons (65 years and older) from the county
councils to the municipalities. This resulted, among
other things, in medically trained nursing staff being
employed in municipalities to provide elderly care. It led
to changes in the professional role of registered nurses
(RNs) (Lundström and Ehnfors, 2001; Tunedal and
Fagerberg, 2001; Kapborg and Svensson, 1999). In
addition, special group residences for persons with
dementia have been developed in Sweden since early
1980s as an alternative to traditional institutions
(Annerstedt, 1995). This has divided elderly care into
two groups: (1) specialization in dementia care and (2)
general care. Furthermore, substantial financial cuts led
to staff reductions (Hertting, 2003) and structural
changes (Ahlberg-Hultén, 1999) in the Swedish health
care sector.
Sandman and Wallblom (1996) studied 842 older
persons living in special housing for municipal care.
Fifty percent of them suffered from dementia. Persons
with dementia were more impaired in all kinds of
functions that those without, and they also had
difficulties in coping independently with daily living.
This implies a greater need of care in persons with
dementia compared to those without. Accordingly,
special group residences for persons with dementia have
been developed (Annerstedt, 1995). The aims of these
units are to create opportunities for more individualized
dementia care and to adjust the care and the environment to the needs of persons with dementia. Hence, the
basic idea of group residences is to offer community,
supervision, and activities in a homelike environment.
Dementia care today is a common specialisation in
elderly care. General care units deal with more diverse
diagnoses, including multiple fragilities, persons needing
care for social reasons, and persons with dementia.
The transfer of elderly care to the municipalities led to
a shift from mainly service tasks during office hours to
more personalized, supervised, and qualified health care
24 h a day (Socialstyrelsen, 1996). RNs, who were
previously employed by the county councils, were now
employed by an authority lacking experience in working
with RNs as a professional group (Lundström and
Ehnfors, 2001; Tunedal and Fagerberg, 2001). Hence, an
encounter between medically trained nursing staff and
socially trained social-service staff occurred (Socialstyrelsen, 1996). Previously, RNs worked closely
with physicians, often in teams. Following the ‘Ädel’
reform, RNs worked on their own, bearing responsibility for larger groups of care receivers, especially
during evenings and weekends (Kapborg and Svensson,
1999). Fewer RNs now have responsibility for larger
groups of older people and even more unwell older
patients (Arbetarskyddsstyrelsen, 2000). Furthermore,
RNs do not participate on a managerial level and hence
have not had the possibility of influencing questions of
care by planning activities (Lundström and Ehnfors,
2001).
The responsibilities of municipalities are to provide
health care up to the level of RNs (SFS—Svensk
författningssamling, 1982). The county councils are
responsible for providing physicians to care for persons
in special housing, i.e. nursing homes, group residences,
retirement homes, and service buildings, and in residents
offering special services, and in organized daytime
activities. The Swedish Institute of Family Medicine
(Familjemedicinska Institutet, 2003) detected problems
experienced by RNs in municipal elderly care, such as a
lack of knowledge among leading employees about the
RNs’ work situation and the increase in the number of
patients without a corresponding increase in resources.
Furthermore, RNs lacked access to specialist physicians
and had too little time for patients. The Swedish
associations of health professionals (Vårdförbundet,
2004) showed that the majority of 300 RNs employed
in the municipality were satisfied with the degree of
influence on their work, but had experienced an
increased workload during the past 3 years.
The majority of RNs worked in some kind of
collaboration with other RNs and/or other occupational
personnel. However, 17% of RNs worked alone.
The lack of time and staff has been shown to be an
obstacle in the work of RNs (Tunedal and Fagerberg,
2001). An increasing problem is to recruit and keep
enrolled nurses and nursing assistants in their positions.
Furthermore, a greater number of them are without
adequate occupationally oriented education (Socialstyrelsen, 2002a).
The problems of recruiting and keeping RNs in
municipal elderly care are considerable and may affect
both care receivers and relatives via decreased quality
(Socialstyrelsen, 2002a). Today there is a shortage of
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RNs in Sweden, for instance, due to rising sick leave
absence (Arbetsmiljöverket, 2002). Work related illness
increased 85% among RNs during 1997–2001 (Arbetsmiljöverket, 2002). A considerable increase in the
number of RN retirements 10 years from 2001 is also
expected, since the majority of working RNs were 40–54
years of age in 2001 (Socialstyrelsen, 2002b). The
Swedish Association of Local Authorities (2003) reported 25% of RNs in permanent employment in the
municipality were 55 years of age or older. Furthermore,
in 2002, almost 1400 (12.5%) RNs, with permanent
employment in municipal care of older and disabled
persons left their positions (Svenska kommunförbundet,
2003). Most of them went to the county councils, but the
number that went to the private sector has more than
tripled since 1997. The situation is further aggravated by
nursing students’ reluctance to work in elderly care. The
work situation of RNs raises concerns about malpractice
and many RNs worry that they might be reported to the
national disciplinary board (Arbetarskyddsstyrelsen,
2000). They need a supportive context to care for older
persons, especially if they or their staff feel they cannot
provide optimal quality care (Fagerberg and Kihlgren,
2001). According to Fagerberg et al. (2000) nursing
students found that RNs working in elderly care were
often isolated with no apparent support system, which in
turn reinforced their ambivalence and reluctance towards future work in elderly care.
Measures of psychosocial working conditions are
often influenced by qualification levels of work and
work stress (Michélsen et al., 1993). The underlying
assumption in stress theory is that a work situation is
perceived individually and may lead to stress reactions,
which influence health and well-being. The demandcontrol model (Karasek, 1979; Johnson and Hall, 1988;
Karasek and Theorell, 1990) measures stress in working
life as a multidimensional concept of mental, social, and
physical variables. The model is often used in studies of
work environment and contributes to understanding
work organization, stress, and health (Theorell, 1993).
The demand-control model deals with the relation
between external psychological demands such as job
demands, time pressure, and conflicting demands.
Demand in human services can be interpreted as
quantitative or emotional (Söderfeldt et al., 1996).
Furthermore, the model deals with possibilities of
decision latitude and social support at work from fellow
workers and supervisors. Decision latitude includes
authority over decisions, such as task control, and skill
utilization, such as how employers’ knowledge is used
and developed (Theorell, 2003; Westlander, 1999). The
model proposes that psychological strains do not result
from a single aspect of demands in a work situation, but
from the joint effects of demands. A range of possible
decisions gives freedom to the worker in meeting
demands. The main hypothesis stipulates that it is high
73
psychological demands combined with low control that
causes adverse psychological and physical health outcomes, and that social support, such as a supervisor
showing care, giving attention, and creating team spirit,
has a buffering effect in relation to the occurrence of
job-related stress. The definition of social support
includes co-workers expressing positive reception, helping and showing personal interest, and the self-perception of the RN as a competent person.
Ahlberg-Hultén’s (1999) retrospective study explored
the changes in the psychosocial work environment that
had occurred during the years 1988–1996 for health care
staffs in comparison with other occupational groups.
The study indicated changes such as a deteriorated
psychosocial work situation for health care staffs. RNs
faced a more intense and challenging work situation
without corresponding developments in support to keep
up with increased demands. Furthermore, health care
staffs experienced higher levels of psychological demands and lower levels of decision latitude compared to
occupational groups working with either ‘things’, or
‘symbols’ (for instance, engineers, statisticians, and
electronic repairmen).
Quality of care is important not only to older persons
in care but also in the work environment of the RN
(Gustafsson and Szebehely, 2001). However, very little
research involving comprehensive investigations of staff
reactions to and experience of changes in the work
situation in municipal elderly care has been published
during the 1990s (Socialstyrelsen, 2002c).
To conclude, organizational changes have occurred in
municipal elderly care in Sweden during the past
decades. First the ‘Ädel’ reform transferred responsibility for the care of older persons from the county
councils to the municipalities. Secondly, the specialisation in dementia care divided elderly care into two
groups: dementia and general care. It is therefore
valuable to compare the work situation of RNs working
solely in dementia care with that of RNs working in
general elderly care. As psychological demands, decision
latitude, social support, and stress seem to be central to
nursing work, these aspects of the work situation will be
illuminated and constitute the focus of this study.
2. Aim
The main focus is to describe working situation of
RNs in municipal elderly care in terms of their
characteristics, psychological demands, decision latitude, and social support. Taking into account the
specific structure of elderly care, another aim is to
compare RNs working solely in dementia care with
those working in general care with older persons of
diverse diagnoses.
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74
3. Method
3.1. Sample
This study was conducted as part of a larger
questionnaire survey, which sought to describe the
RN’s work conditions, competence, and future prospects in municipality elderly care in a large Swedish
city. The study was non-experimental and descriptive in
design, with a survey research approach (Polit and
Hungler, 1999). The study was approved by the Ethics
Committee of Karolinska Institutet, Stockholm.
The target population was RNs (n ¼ 342) working in
elderly care divided into two groups, 143 in Dementia
Care (DC) and 199 in General Care (GC). The RNs
worked at 60 special housing with underlying units
including those offering daytime activities, and of these
33 were in DC, 20 were in GC, and seven had part DC
and part GC. The total number of participating RNs
was 213, comprising 62.3% of the target population;
44.6% (95) of the 213 nurses worked in DC and 55.4%
(118) in GC (see Fig. 1).
3.2. Instruments
The questionnaire was compiled mainly from three
questionnaires, developed by Fahlström (1999), Hagström et al. (1996), and Aronsson et al. (1992). The
questions were carefully selected as regards content to
suit this study. Modification of some questions was
undertaken to suit the occupational group of RNs; for
the same reason, some new questions were added. Areas
investigated consisted of background characteristics,
such as age, gender, education, employment conditions,
and years working as an RN, and the work situation
regarding demands, authority over decisions, and
support.
The questions were presented mainly with response
categories, and the majority of them were rated in
ordinal scales; for example, a Likert-type scale of 1–5
ranged from ‘‘not agree at all’’ to ‘‘agree totally’’,
sometimes with the alternative ‘‘not relevant/do not
know’’. The ‘‘not relevant/do not know’’ responses were
handled as missing data in the analysis. The participants
specified whether they worked in DC or GC in the
questionnaire, and they were given an opportunity to
add their own comments at the end of the questionnaire.
The questionnaire contained a limited number of
nominal and ratio scales.
3.3. Procedure
The questionnaire was tested on 10 RNs working in
special housing for older persons. Five of them worked
in DC and the rest in GC. This was done in order to
control the logistics of the trial, relevance of the
questions, usage, and expected time to fill in the
questionnaire (Altman, 1996). Data were collected
during a 1-year period (2003–2004). Local municipal
managers with overarching responsibility for elderly
care and the managers of each special housing unit for
older persons approved the study. The managers of the
special housing units provided the information on the
number of RNs working, whether they worked in DC or
GC, and their names. Managers did not receive
information about specific questions on the questionnaire asking participants to comment on the support
provided by their managers. Some managers asked for
and were given a copy of an unanswered questionnaire
before agreeing to participate. The questionnaires were
disseminated in sealed envelopes to the RNs, either by
their managers or the principal investigator.
The sealed envelope to the RNs included an
introductory letter explaining the study purpose, information that data would be kept confidential and the
RNs’ identity protected, and a postage-paid return
envelope. Three reminders were sent directly to RNs
when necessary. Participation was voluntary.
To record the motives of non-respondents (n ¼ 129), a
form was distributed to them, and they were asked to
respond to the following statement: ‘‘I have not
answered the questionnaire becausey’’. Non-respondents’ motives were analysed by their manifest content
and were discussed with an outsider researcher.
3.4. Data analysis
Registered nurses
342
Dementia Care
143
General Care
199
48 refused
81 refused
95 (66.4%) participated
118 (59.3%) participated
213 (62.3%)
Fig. 1. The number of participated registered nurses and their
response rate.
The statistical analysis was performed using the
Statistical Package for the Social Sciences (SPSS) for
Windows version 11.5. p-Values of less than .05 were
considered as statistically significant. Statistical tests
used were the chi-square test (w2) to examine the
distribution of one variable in two independent groups,
and the Mann–Whitney U-test (z) to examine differences
between two independent samples (Altman, 1996). The
majority of variables were measured on an ordinal scale;
therefore, statistical methods appropriate for these
types of data were used throughout. The Wilcoxon
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75
differed significantly between groups (z ¼ 2:457, po:05).
Correlational analysis revealed weak associations. These
correlations are not reported here but are available from
the authors on request.
The median of Nursing examination year (DC n ¼ 93,
GC n ¼ 117) was 1983 in DC (min–max, 1956–2001)
and 1981 in GC (min–max, 1956–2002). The majority of
RNs were female in both groups (DC 95%, GC 92%).
They had worked as RNs 17 years (median) in the DC
group (min–max, 1–51) and 19 years in the GC group
(min–max, 0.75–43). RNs (DC n ¼ 94, GC n ¼ 116) had
worked 3 years at their current workplace in the DC
group (min–max, 0.08–40) and just over 112 years in the
GC group (min–max, 0.08–25). DC nurses had worked 9
years as RNs in elderly care (min–max, 0.25–30) and GC
nurses six years (min–max, 17–29). DC nurses had
worked a significantly longer time at their current
workplaces (z ¼ 2:939, po:01) and as RNs in elderly
care (z ¼ 2:286, po:05).
Most of the RNs in both groups were permanently
employed (DC 85%, GC 87%). The median working
time among permanently employed nurses was full time
in both groups (DC min–max, 46%–100%; GC min–
max, 25%–100%). There was a significant difference
between groups in terms of working hours among those
permanently employed (z ¼ 2:006, po:05).
signed-rank test (z) was used to calculate differences
between two paired observations with the purpose of
revealing any differences in the degree of conflicting
demands within groups. This test takes into account the
magnitude of the positive and negative differences
within a group (Altman, 1996). Spearman’s analysis of
rank correlation (rho) was used to measure the
associations between age and all the variables defined
in this study (Altman, 1996). The internal loss of data
was minimal and data were neither replaced nor
imputed.
4. Results
4.1. Non-respondents’ reasons to not participate
Non-respondents’ (n ¼ 129) reasons for not participating in the study were primarily lack of time,
too extensive questionnaire, and high workload (see
Table 1).
4.2. Subject characteristics
RNs had median age 52 years in DC (min–max,
25–76) and 49 years in GC (min–max, 23–68). Age
Table 1
Non-respondents’ reasonsa to not participate in the study
Type of reasons
Lack of time
Too extensive questionnaire
High workload
Private, other than on the sick leave (e.g. did not feel good,
home situation, lack of initiative)
Do not want to participate in this study, any other studies,
or studies with questionnaire
No anonymity
On sick leave
Ended the employment
Insufficient experience of current work place/elderly care
Changed work condition
Too private questions
Unsuitable point of time
Received other questionnaires at the same time
Complicated questions
No relevant questions
Exhausted over the work situation
Answered questionnaire was not received
Difficulties with usage
a
Registered nurse group
DC n ¼ 48
GCb n ¼ 75
Totalb n ¼ 123
n (%)
n (%)
n (%)
18
10
14
12
27
26
17
9
45
36
31
21
(37)
(21)
(29)
(25)
2 ( 4)
—
2
3
—
3
—
3
—
3
2
—
1
—
(4)
(6)
(6)
(6)
(6)
(4)
(2)
All questions were open-ended, hence one to four motives were given.
Six respondents were missing.
b
(36)
(35)
(23)
(12)
10 (13)
8
6
4
6
2
4
1
3
—
1
2
1
1
(11)
(8)
(5)
(8)
(3)
(5)
(1)
(4)
(1)
(3)
(1)
(1)
(37)
(29)
(25)
(17)
12 (10)
8
8
7
6
5
4
4
3
3
3
2
2
1
(6)
(6)
(6)
(5)
(4)
(3)
(3)
(2)
(2)
(2)
(2)
(2)
(2)
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Ten per cent (10%) in DC and 13% (15) in GC were
employed on an hourly contract directly by the
organization. Four per cent (4%) RNs in DC were
employed full time by deputyship or project. RNs
employed on an hourly basis had a median working
time of 80 h a month in the DC group (min–max,
30–148) and 120 h a month in the GC group (min–max,
30–200).
4.3. Psychological demands
There were significant differences between groups
regarding knowledge and emotional demands, easy or
hard work tasks, desire to have close and personal
contact with care receivers, and whether such contact
was possible. Table 2 provides a summary of statistics
for psychological work demands across groups.
Both groups (DC n ¼ 90, GC n ¼ 118) scored the
desire to have close and personal contact with care
receivers higher than the opportunity to have near and
personal contact with care receivers (DC higher 40%,
same 51%, lower 9%, z ¼ 3:952 po:001; GC higher
29%, same 58%, lower 14%, z ¼ 2:070 po:05).
In both groups (DC n ¼ 93, GC n ¼ 115) more
perceived that personal workload during the last 2 years
had increased rather than decreased (DC increased 41%,
decreased 17%, unaltered 42%; GC increased 51%,
decreased 16%, unaltered 33%). The risk of making a
mistake (DC n ¼ 95, GC n ¼ 117) was rarely or
occasionally perceived as a psychological burden by
65% in DC and 73% in GC, always or often by 12% in
DC and 15% in GC, and never by 23% in DC and 12%
in GC.
The fact that the national disciplinary board can
check up on the work of RNs was perceived by both
groups more as a support (DC 44%, GC 48%) than a
stress (DC 20%, GC 21%). Mixed feelings of stress and
support were perceived by 36% in DC and 31% in GC.
The majority of RNs in both groups (DC n ¼ 94, GC
n ¼ 116) felt, on a scale of 1 (absolutely not) to 5 (yes,
without hesitation), working in elderly care was
psychologically stressful in the long run (median 4, inter
quartile range 3–5).
4.4. Authority of decisions
The decision latitude in terms of authority of
decisions was analysed across groups. There was
significant difference between groups regarding the
RN’ possibility of postponing planned work tasks when
they had too much to do (Table 3).
4.5. Social support
Data on social support at work across groups are
shown in Tables 4 and 5. There were significant
differences between groups regarding perceived support
from management, whether they received valuable
advice on how to perform work tasks, and the degree
to which RNs felt they were appreciated by team
members. Significant differences were also revealed in
RNs’ opinions on whether their work achievement was
judged as valuable by staff in higher positions and other
occupational groups.
To further explore the potential of social support,
RNs’ discussions with colleagues and other nursing staff
about difficulties in their work were analysed (Table 5).
There were significant differences between groups when
discussing with nursing staff other than RNs concerning
theoretical knowledge (po:01), ethical reasoning
(po:05), teaching (p ¼ :001), leadership (p ¼ :001), and
contact with care receivers’ relatives (po:01).
Collaboration at work during the last two years was
RNs (DC n ¼ 93, GC n ¼ 115) perceived as unaltered
(DC 52%, GC 59%), improved (DC 33%, GC 28%),
and impaired (DC 15%, GC 13%).
5. Discussion and conclusions
The main purpose of this study was to extend
knowledge concerning the work situation of RNs in
municipal elderly care. This was accomplished by
comparing RNs working in dementia care with those
working in general care. The main findings indicated
that RNs were older rather than younger (average age
close to fifty) and they perceived high levels of time
pressure. RNs in dementia care had worked longer at
their current workplace and in elderly care than RNs in
general care. In dementia care, emotional demands and
conflicting demands were greater than in general care.
RNs in both groups perceived a greater opportunity to
plan and perform daily work tasks than to influence
their work situations. Support from management and
fellow workers was perceived as generally high.
Both groups had few male nurses. This reflects the
female dominance in nursing care. The oldest RN
participating in our study worked in dementia care,
and surprisingly, was well over normal retiring age, 76
years. RNs in both groups had a high median age, and it
was significantly higher in dementia care. The high
median age in both groups indicates a high number of
retirements in 10–14 years. Our results are in line with
predictions of a considerably increased number of cases
of RN retirement in 10 years (Socialstyrelsen, 2002b).
To retain RNs after retirement age seems to be one
solution to the problem of providing RNs for municipal
elderly care. Therefore our results support the earlier
argument (Arbetsmiljöverket, 2004) that it is necessary
to adapt work conditions to older staff. At the
same time, it is reasonable to argue that long-term
life experience and professionalism lead to personal
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77
Table 2
Psychological work demands across groups, dementia care (DC) and general care (GC)
Variables
Time demandsb
Knowledge demandsb
Emotional demandsb
Responsibility/authority which agree with work taskse
My intermediate position is difficult to handle in my
responsibility as a leadere
Uncertain to manage the worke
Left often alone to take responsibility of my worke
Torn between many work taskse
Working under time pressuref
Manage to finish work tasks within working hoursg
Difficulties to get peace and seclusion needed to perform
certain work tasksi
Too many work tasks which negatively affects the
opportunities to work effectivelyi
Personal work amountj
Easy or hard work tasksk
Feeling of insufficiency for care receivers need of helpe
Desirability to have close and personal contact with
care receiversl
Possibility to have near and personal contact with care
receiversl
DC (n ¼ 95)
GC (n ¼ 118)
Median
(quartiles)a
Mean
rank
Median
(quartiles)a
Mean
rank
Mann–Whitney
U (z)
(3–4)c
(3–3)c
(3–4)c
(3–5)c
(2–4)d
104.63
113.32
113.79
109.92
111.35
4
3
3
4
2
(3–4)d
(3–3)d
(3–3)d
(3–5)c
(2–3)d
106.20
99.16
98.78
102.85
99.91
.668,
2.082,
2.277,
.885,
1.397,
n.s.
po:05
po:05
n.s.
n.s.
1 (1–2)
4 (3–5)c
2.5 (1–4)c
3 (2–4)
3 (2–3)d
3 (2–4)
103.96
111.26
105.25
103.36
100.60
100.54
1 (1–2)d
4 (3–5)d
2.5 (1.25–3)d
4 (2–5)c
3 (2–3)h
3 (2.75–4)c
107.67
100.84
105.70
109.05
107.65
111.34
.537,
1.303,
.055,
.718,
.993,
1.314,
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
3 (2–3)
101.43
3 (2–3.5)d
109.75
1.032, n.s.
4
3
3
3
(3–5)
(3–3)
(2–4)c
(2–3)h
107.52
115.11
109.35
120.53
4
3
3
2
(4–5)c
(3–3)c
(2–4)
(2–3)
105.67
99.51
104.23
93.78
.232,
2.325,
.623,
3.441,
2 (2–2)m
113.39
2 (2–2)
4
3
3
4
3
97.72
n.s.
po:05
n.s.
po:01
2.457, po:05
a
The 25th and 75th percentile.
Scale range 1 ¼ absolutely too low, 5 ¼ absolutely too high.
c
One internal loss.
d
Two internal losses.
e
Scale range 1 ¼ totally disagree, 5 ¼ totally agree.
f
Scale range 1 ¼ never, 2 ¼ little (1/10) of the time, 3 ¼ about 1/4 of the time, 4 ¼ half the time, 5 ¼ about 3/4 of the time,
6 ¼ always.
g
Scale range 1 ¼ never, 2 ¼ mostly not, 3 ¼ in most cases, 4 ¼ always.
h
Three internal losses.
i
Scale range 1 ¼ never, 2 ¼ seldom, 3 ¼ sometimes, 4 ¼ quite often, 5 ¼ in most cases.
j
Scale range 1 ¼ mostly too little to do, 2 ¼ too little to do sometimes, 3 ¼ just right, 4 ¼ too much to do sometimes, 5 ¼ mostly too
much to do.
k
Scale range 1 ¼ mostly too easy, 2 ¼ too easy sometimes, 3 ¼ just right, 4 ¼ too hard sometimes, 5 ¼ mostly too hard.
l
Scale range 1 ¼ not with anyone, 2 ¼ with few, 3 ¼ with all.
m
Five internal losses.
b
maturity and a greater capacity to cope with the work
situation. This would support with Tunedal and Fagerberg’s (2001) description of mental strength, confidence,
and independence combined as one fundamental aspect
of the RN’s professional role in municipal elderly care.
The high age of RNs was also reflected in their
examination years and the number of years they
had worked as an RN. Dementia nurses had
worked significantly longer at their current workplace
and as an RN in elderly care. Furthermore, permanently
employed RNs in dementia care worked significantly
longer hours. Altogether, this may reflect a
greater stability at the work site in dementia care than
in general care. The length of current employment in
both groups was remarkably short, in spite of
long careers as RNs. This may reflect large shifts in
staffing because RNs leave their employment
(Svenska kommunförbundet, 2003) and have a high
sick-leave absence (Arbetsmiljöverket, 2002). Our results
showed that RNs in both groups felt high time
pressure, and they are consistent with the findings of
Tunedal and Fagerberg (2001) and Hagström et al.
(2000). RNs in general care worked under time pressure
half of the time, which was twice as much as those in
dementia care. A substantial proportion of nurses
reported they were not able to finish their work tasks
ARTICLE IN PRESS
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K. Josefsson et al. / International Journal of Nursing Studies 44 (2007) 71–82
Table 3
Authority of decisions at work across groups, dementia care (DC) and general care (GC)
Variables
Possibility to:
Plan my work tasks as I consider the most
efficient wayb
Perform my work tasks as I consider the most
efficient wayb
Postpone planned tasks, for instance when
I have too much to dob
Influence decisionsd
Influence important decisionsf
Have enough of large influence on decision
on the wardb
DC (n ¼ 95)
GC (n ¼ 118)
Median
(quartiles)a
Mean
rank
Median
(quartiles)a
Mean
rank
Mann–Whitney
U (z)
4 (3–4)
104.44
4 (3–5)c
108.18
.463, n.s.
4 (3–5)
105.54
4 (3–5)c
107.28
.215, n.s.
4 (3–4)
115.94
3 (3–4)c
98.84
3 (3–4)e
3 (2–3)g
3 (3–4)
111.04
102.73
106.47
3 (2–4)c
3 (2–3)e
3 (3–4)c
101.09
105.90
106.52
2.103, po:05
1.223, n.s.
.409, n.s.
.006, n.s.
a
The 25th and 75th percentile.
Scale range 1 ¼ never, 2 ¼ seldom, 3 ¼ sometimes, 4 ¼ quite often, 5 ¼ most often.
c
One internal loss.
d
Scale range 1 ¼ totally disagree, 5 ¼ totally agree.
e
Two internal losses.
f
Scale range 1 ¼ not at all, 2 ¼ in a low degree, 3 ¼ in a certain degree, 4 ¼ in a high degree.
g
Three internal losses.
b
during working hours, in spite of the fact that their tasks
were not too difficult.
Furthermore, RNs in dementia care indicated higher
knowledge and emotional demands, and harder work
tasks than nurses in general care, which can be understood in the light of the specific ethical and psychiatric
needs of dementia care. The majority of RNs were more
likely to feel supported than stressed by the fact
that their work might be monitored by the national
disciplinary board, contrary to an earlier report in
which RNs felt more stress than support (Arbetarskyddsstyrelsen, 2000). Furthermore, 51% of the RNs
in general care and 41% in dementia care estimated
that their workloads had increased during the past two
years is in line with a recent study (Vårdförbundet,
2004). It is also in agreement with findings of
high psychological demands in health care in general
(Hertting, 2003; Hagström et al., 2000; Ahlberg-Hultén,
1999).
The possibility of having close and personal contact
with care receivers was scored more highly in dementia
care. Reasons for this might depend on the organization
of dementia care, with small and homelike units and a
well thought-out care philosophy. It might also depend
on consequences of the past decade’s research, development projects, and education in dementia care. Furthermore, the meaning of ‘close and personal contact’ is a
matter of definition. Also, conflicting demands were
high within both groups, but even higher in dementia
care, since the desire to have close and personal contact
was higher than the opportunity to do so. This may
cause problems in recruiting and keeping RNs. Furthermore, there is a need to lower conflicting demands
within both groups, specifically in dementia care, as high
demands together with low influence can cause adverse
psychological and physical health outcomes (Theorell,
1993; Karasek and Theorell, 1990).
Our findings that RNs in both groups perceived their
work tasks as being ‘just right’ in degree of difficulty are
in agreement with previous research in different
specialities (Hagström et al., 2000). This can be
explained by long-term professional experience in
coping with work tasks, reducing uncertainty in managing daily tasks. The possibility of planning and
performing work tasks was higher in both groups than
the possibility of influencing the work situation in a
wider context, such as in decision-making. This is in line
with a study on different specialities (Hagström et al.,
2000). Those authors indicated it may be related to
efficiency measures and substantial financial cutbacks in
health care. Dementia nurses had a greater opportunity
to postpone planned tasks, for instance, when they had
too much to do. Lundström and Ehnfors (2001) also
demonstrated the lack of RNs’ influence in questions of
care at a managerial level in municipal elderly care. It
could be argued that failing to make use of RNs’
influence is a waste of competent resources, especially as
RNs are the only professional group with education and
certification in advanced nursing (Socialstyrelsen, 1995;
Socialstyrelsen, 1993).
Our results indicated that RNs in both groups had
high social support from management and fellow
ARTICLE IN PRESS
K. Josefsson et al. / International Journal of Nursing Studies 44 (2007) 71–82
79
Table 4
Social support at work across groups, dementia Care (DC) and general care (GC)
Variables
Support from the managementb
Support from colleaguesb
Support from subordinated staffb
Staff give the support I need (in the context as a leader)b
Nearest management give me the opportunity to talk
with them/her/him about difficulties in workb
Nearest management is an asset to me in critical situationsb
Receive valuable advice how to perform work tasks b
Characterize the work climate in terms of supporting or note
Staff in higher position judge my work achievement
as valuablef
Nearest management judge my work achievement
as valuablef
RNs in the same position as me judge my work achievement
as valuablef
Staff in lower position judge my work achievement
as valuablef
Other occupational groups judge my work achievement
as valuablef
Nearest management appreciate meg
Fellow-workers appreciate meg
I and my fellow-workers work well together in a teamg
DC n ¼ 95
GC n ¼ 118
Median
(quartiles)a
Mean
rank
Median
(quartiles)a
Mean
rank
Mann–Whitney
U (z)
4
4
4
4
4
(3–5)c
(3–5)
(3–5)d
(3–5)d
(3–5)c
116.48
106.75
107.19
104.73
110.49
4
4
4
4
4
(3–4)c
(4–5)c
(3–4)c
(3–4)c
(3–5)c
97.58
106.30
104.15
106.12
102.39
2.341,
.056,
.385,
.173,
.992,
po:05
n.s.
n.s.
n.s.
n.s.
4
3
5
4
(3–5)d
(2–4)c
(5–6)
(4–5)d
113.06
115.27
112.66
118.92
3
3
5
4
(3–5)c
(2–3)d
(4–6)c
(3–4)d
99.49
97.58
101.50
93.84
1.663,
2.169,
1.357,
3.111,
n.s.
po:05
n.s.
po:01
4 (3.75–5)c
113.03
4 (3–5)c
100.35
1.586, n.s.
5 (4–5)c
113.20
4 (4–5)c
100.22
1.667, n.s.
4 (4–5)c
109.47
4 (4–5)c
103.21
.793, n.s.
4 (4–5)c
114.99
4 (3.25–5)d
97.81
2.180, po:05
3 (3–4)d
3 (3–4)d
3 (3–4)d
105.35
103.77
114.20
3 (3–4)c
3 (3–4)c
3 (2.50–4)c
105.62
106.87
98.59
.034, n.s.
.441, n.s.
1.987, po:05
a
The 25th and 75th percentile.
Scale 1 ¼ totally disagree, 5 ¼ totally agree.
c
One internal loss.
d
Two internal losses.
e
Scale range 1 ¼ a cold, open and humiliating climate, 7 ¼ a warm, open and supporting climate.
f
Scale range 1 ¼ never,2 ¼ seldom, 3 ¼ sometimes, 4 ¼ quite often, 5 ¼ mostly.
g
Scale range 1 ¼ not at all, 2 ¼ to a low degree, 3 ¼ to a certain degree, 4 ¼ to a high degree.
b
workers. Fagerberg and Kihlgren (2001) state that a
supportive context is an important source of mental
nourishment for RNs in elderly care, especially if they
experience that they or the staff cannot provide
adequate care. Dementia nurses received support from
staff in higher positions to a higher degree than RNs in
general care. In addition, RNs in dementia care received
valuable advice on how to perform work tasks and
worked well together in a team. These findings may
reflect organizational differences in elderly care. The
demand-control model (Karasek and Theorell, 1990)
also points out the importance of social support,
specifically for its buffering effect on work-related stress.
Contrary to RNs’ perceptions in our sample, Fagerberg
et al. (2000) reported that nursing students found RNs
in elderly care often were isolated with no apparent
support system. However, students’ perceptions might
have been related to their needs of support at the
beginning of a new profession.
Results showed that RNs in this study preferred to
discuss work difficulties with RN colleagues before other
nursing staff. This may be due to the high number of
staff without adequate occupationally oriented education (see Socialstyrelsen, 2002a). It also demonstrates
the importance of having access to other RNs for its
buffering effect on job-related stress (Karasek and
Theorell, 1990), specifically when RNs in municipal
elderly care often work alone without close contact with
physicians (Familjemedicinska Institutet, 2003; Kapborg and Svensson, 1999). It may also be important for
RNs to have access to other RNs and the opportunity to
support each other since the ‘Ädel’ reform, after which
they have been employed by an authority lacking
experience working with RNs as a professional group
(Lundström and Ehnfors, 2001; Tunedal and Fagerberg,
2001). The present findings indicate that RNs in
dementia care, compared to general care, were more
willing to discuss with nursing staff other than RNs
about difficulties regarding theoretical knowledge and
leadership. This may indicate a less hierarchical staff
structure and smaller work units in dementia care than
in general care.
ARTICLE IN PRESS
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K. Josefsson et al. / International Journal of Nursing Studies 44 (2007) 71–82
Table 5
RNs discussions about difficulties in their work across groups, dementia care (DC) and general care (GC)
Variablesa
DC (n ¼ 95)
GC (n ¼ 118)
Median
(quartiles)b
Mean
rank
Median
(quartiles)b
Mean
rank
Mann–Whitney
U (z)
Discussions with colleagues, RNs, about difficulties regarding
Theoretical knowledge
3 (3–3.75)c
Clinical knowledge, methods and common praxis
3 (3–4)d
Ethical reasoning
3 (3–4)d
Teaching
3 (3–3)c
Leadership
3 (3–4)d
Contact with care receivers
3 (3–4)d
Contact with care receivers relatives
3 (3–4)d
Collaboration with RNs
3 (2–4)d
100.17
103.42
112.44
107.01
111.02
102.35
105.85
106.06
3
3
3
3
3
3
3
3
(2–3)d
(3–4)c
(3–3)c
(3–3)c
(2–3)d
(3–4)d
(3–4)d
(3–3)c
100.00
104.97
98.08
101.59
100.17
107.12
104.32
103.23
1.346,
.140,
1.908,
.727,
1.430,
.663,
.201,
.367,
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
Discussions with nursing staff other than RNs about difficulties regarding
Theoretical knowledge
2 (1.75–3)e
Clinical knowledge, methods and common praxis
2 (2–3)e
Ethical reasoning
3 (2–4)
Teaching
3 (2–3)d
Leadership
2 (2–3)
Contact with care receivers
3 (3–4)e
Contact with care receivers relatives
3 (3–4)e
Collaboration with RNs
2 (1–2)d
117.34
113.53
115.50
119.90
121.11
113.03
116.88
110.72
2
2
3
2
2
3
3
1
(1–2)e
(1–3)d
(2–3)c
(1–3)d
(1–2)d
(2–3)d
(2–3)d
(1–2)c
96.89
99.00
97.24
93.06
93.63
99.40
96.28
99.47
2.576,
1.825,
2.336,
3.341,
3.448,
1.757,
2.617,
1.464,
po:05
n.s.
po:05
po:01
po:01
n.s.
po:01
n.s.
a
Scale range 1 ¼ never, 2 ¼ mostly not, 3 ¼ in most cases, 4 ¼ always.
The 25th and 75th percentile.
c
Three internal losses.
d
Two internal losses.
e
One internal loss.
b
Relatively little interest has been paid to RNs’ work
environment and working conditions, especially their
work situation in municipal elderly care (Socialstyrelsen,
2002c). Some studies do highlight the working conditions of RNs. However, RNs are not a homogeneous
professional group as, in different countries, the
organization and tasks differ. Given the lack of
investigations to which these results could be compared,
there is a need to replicate this study. Consequently,
generalizations beyond this study should be made with
caution. Furthermore, it is important to emphasize that
our study did not measure objective indicators in the
work environment. Although this applies to most
questionnaires, it is critical to note that our study
described participants’ perceptions of given indicators in
their work, mostly via closed questions. At the same
time, there are a number of questions about RNs’
former work situations and why they quit that need
clarification.
In conclusion, this study highlighted parts of RNs’
work situation in municipal elderly care and is
particularly pertinent for managers. Results indicated
RNs are of high ages, especially in dementia care.
RNs in dementia care had worked longer at their
current workplaces and as RNs in elderly care. RNs in
both groups perceived high levels of time pressure.
Demands concerning knowledge and emotional and
conflicting demands were greater in dementia care. RNs
in both groups perceived a greater possibility of
planning and performing work tasks than influencing
their work situations in a wider context. RNs in
dementia care perceived harder work tasks and had
greater opportunities to postpone planned tasks. Support at work was perceived as generally high from
management and fellow workers and was perceived
higher in dementia care. Taking into account the
demand-control model stipulating a combination of
high psychological demands with low control causing
adverse psychological and physical health outcomes, our
results indicate the importance of decreasing RNs’ time
pressure and increasing their influence on decisions
made at work.
To the best of our knowledge, no study has been
published on the work situation in Swedish municipal
elderly care in which, demands, influence, and support
are studied comparing RNs in dementia care and general
care. Hopefully, these findings will be useful in recruiting
and retaining RNs, who are an irreplaceable staff
resource in municipal elderly care and essential to
meeting present day and future demands.
ARTICLE IN PRESS
K. Josefsson et al. / International Journal of Nursing Studies 44 (2007) 71–82
Acknowledgement
The Swedish Society of Nursing and the Swedish
Institute of Family Medicine provided research funding
to Karin Josefsson. The Erik and Edith Fernström
Foundation for Medical Research and the Alzheimer
Foundation, Sweden, provided funding to Tarja-Brita
Robins Wahlin. We are grateful to the registered nurses
who so willingly agreed to share with us their perceptions of their working situations in spite of work
pressures and demands.
References
Ahlberg-Hultén, G., 1999. Psychological demands and decision
latitude within health care work. Relation to health and
significance. Dissertation, Department of Psychology,
Stockholm University, Sweden.
Altman, D.G., 1996. Practical Statistics for Medical Research.
Chapman & Hall, London.
Annerstedt, L., 1995. On group-living care for demented elderly
care. Experiences from the Malmö Model. Dissertation, The
Department of Community Health Sciences, Malmö and
the Department of Geriatric Psychiatry, Lund, Lund
University, Sweden.
Arbetarskyddsstyrelsen, 2000. Stress och belastning i vård och
omsorg. Rapport 2000:8. Arbetarskyddsstyrelsen, Stockholm.
Arbetsmiljöverket, 2002. Sjuksköterskor, Korta faktasiffror Nr
7. Arbetsmiljöverket, Statistikenheten, Solna.
Arbetsmiljöverket, 2004. Anpassning av arbetsförhållandena
med åldersperspektiv. En handledning om att anpassa
arbetsmiljön till äldre arbetstagares särskilda förutsättningar i fysiskt och psykiskt avseende. Arbetsmiljöverket,
Solna.
Aronsson, G., Lantz, A., Westlander, G., 1992. Rapport
1992:11. Akademiker under 1990-talet. En studie av
SACO-medlemmarnas arbetsvillkor. Undersökningsinstrument och studiens bakgrund. Arbetsmiljöinstitutet, Enheten
för socialpsykologi, Solna.
Fagerberg, I., Kihlgren, M., 2001. Registered nurses’ experiences of caring for the elderly in different health-care areas.
International Journal of Nursing Practice 7, 229–236.
Fagerberg, I., Winblad, B., Ekman, S., 2000. Influencing
aspects in nursing education on Swedish nursing students’
choices of first work area as graduated nurses. Journal of
Nursing Education 39 (5), 211–218.
Fahlström, G., 1999. Ytterst i organisationen. Om undersköterskor, vård- och sjukvårdsbiträden i äldreomsorg.
Avhandling, Institutionen för folkhälso- och vårdvetenskap,
enheten för socialmedicin, Uppsala universitet.
Familjemedicinska Institutet, 2003. Problem Detection Study—
sjuksköterskor och enhetschefer inom kommunal äldrevård
och hemsjukvård. Familjemedicinska Institutet, Stockholm.
Gustafsson, R.Å., Szebehely, M., 2001. Working conditions
and welfare opinions in old-age care—a survey-based case
study of politicians and staff in three municipalities.
Investigation Report 2001:9, National Institute for Working
Life.
81
Hagström, T., Gamberale, F., Sconfienza, C., 1996. Det goda
arbetet. Ungdomars villkor nu och i framtiden. Beskrivning
av frågeformulär, 10. Arbetslivsinstitutet, Solna.
Hagström, T., Johansson, G., Westerholm, P., 2000. Sjuksköterskors socialisation in i arbetsliv och yrke. En longitudinell studie. Arbetslivsrapport 2000:15. Arbetslivsinstitutet,
Solna.
Hertting, A., 2003. The Health Care Sector: a challenging or
draining work environment. Psychosocial work experiences
and health among hospital employees during the Swedish
1990s. Dissertation, The Department of Public Health
Sciences, Division of Psychosocial Factors and Health,
Karolinska Institutet, Stockholm, Sweden.
Johnson, J.V., Hall, E.M., 1988. Job strain, work place
social support, and cardiovascular disease: a cross-sectional
study of a random sample of the Swedish working
population. American Journal of Public health 78,
1336–1342.
Kapborg, I., Svensson, H., 1999. The nurse’s role in drug
handling within municipal health and medical care. Journal
of Advanced Nursing 30 (4), 950–957.
Karasek, R., 1979. Job demands, job decision latitude, and
mental strain: implications for job redesign. Administrative
Science Quarterly 24, 258–308.
Karasek, R., Theorell, T., 1990. Healthy Work: Stress,
Productivity, and the Reconstruction of Working Life.
Basic Books, New York.
Lundström, U., Ehnfors, M., 2001. Sjuksköterskans yrkesansvar inom kommunal hemsjukvård. En observations- och
intervjustudie 2001:5. Örebro Universitet, Örebro.
Michélsen, H., Härenstam, A., Nordemar, R., Theorell, T.,
1993. Stockholm Music I Study Group. Bakgrund och
uppläggning av metodprövning av formuläret Psykosociala
frågor. In: Hagberg, M., Högstedt, C. (Eds.), Utvärdering
av metoder för att mäta hälsa och exponeringar i
epidemiologiska studier av rörelseorganens sjukdomar.
MUSIC Books, Stockholm, pp. 141–145.
National Board of Health and Welfare, 1996. The ‘‘Ädel
Reform’’ Final Report 1996. English summary in: Ädelreformen. Slutrapport. Socialstyrelsen följer upp och utvärderar 1996:2. Socialstyrelsen, Stockholm, pp. 85–88.
Polit, D.F., Hungler, B.P., 1999. Nursing Research. Principles
and Methods, sixth ed. Lippincott, New York.
Sandman, P.O., Wallblom, A., 1996. Characteristics of the
demented living in different settings in Sweden. Acta
Neurologica Scandinavica Supplementum 168, 96–100.
SFS—Svensk författningssamling 1982:763. Hälso- och sjukvårdslagen.
Socialstyrelsen, 1993. Socialstyrelsen allmänna råd om omvårdnad inom hälso-och sjukvården 1993:17. Fritzez,
Stockholm.
Socialstyrelsen, 1995. Kompetensbeskrivningar för sjuksköterskor och barnmorskor. Allmänna råd från Socialstyrelsen
1995:5. Fritzez, Stockholm.
Socialstyrelsen, 1996. Ädelreformen. Slutrapport. Socialstyrelsen följer upp och utvärderar 1996:2. Socialstyrelsen,
Stockholm.
Socialstyrelsen, 2002a. Nationell handlingsplan för äldrepolitiken—Slutrapport. Linköpings tryckeri, Linköping.
Socialstyrelsen, 2002b. Statistik över hälso- och sjukvårdspersonal 2001-12-31. Socialstyrelsen, Stockholm.
ARTICLE IN PRESS
82
K. Josefsson et al. / International Journal of Nursing Studies 44 (2007) 71–82
Socialstyrelsen, 2002c. Arbetsorganisationen inom äldreomsorgen. En litteraturstudie. Socialstyrelsen, Stockholm.
Söderfeldt, B., Söderfeldt, M., Muntaner, C., O’Campo, P.,
Warg, L-E., Ohlson, C-G., 1996. Psychosocial work
environment in human service organizations: a conceptual
analysis and development of the demand-control model.
Social Science and Medicine 9 (42), 1217–1226.
Svenska kommunförbundet, 2003. Rekrytera och behålla
sjuksköterskor. Retrieved June 23, 2004, from http://www.
lf.svekom.se/artikel.asp?C=1803&A=3749.
Theorell, T., 1993. Krav-kontroll-stöd. Ny modell i arbetsmiljöforskning. Läkartidningen 42 (90), 3683–3686.
Theorell, T., 2003. Psykosocial miljö och stress. Studentlitteratur, Lund.
The Swedish Association of Local Authorities, 2003. Swedish
Elderly Care 2003. Retrieved January 3, 2005, from http://
uno.svekom.se/brsbibl/kata_documents/doc34887_1.pdf.
Tunedal, U., Fagerberg, I., 2001. The challenge of being a
nurse in community eldercare. Vård i Norden 21 (2),
27–32.
Westlander, G., 1999. People at Work. Investigating Social–
psychological Contexts. Studentlitteratur, Lund.
Vårdförbundet, 2004. Sjuksköterskorna om äldrevården. Rapport 2004:1. Vårdförbundet, Stockholm.