A Meaningful Life for Older Persons Receiving Municipal Care — Unit Leaders ’ Perspectives

Introduction: In Sweden, new national guidelines for elderly care have been introduced containing core values and local guarantees of dignity that highlight the need for dignity, well-being and the organisation of the older person’s daily life, so it is perceived as meaningful. Unit leaders play a crucial role in health care organisations when guidelines are to be implemented. Aim: The aim was therefore to describe unit leaders’ experiences about what constituted a meaningful daily life for older persons receiving municipal care and the opportunities and obstacles that might exist. Method: Repeated interviews using reflective conversations with nine leaders were performed and analysed with qualitative content analysis. Results: Unit leaders felt a shared vision regarding a meaningful life was needed. Daily routines and habits that promoted independence, a feeling of community together with familiarity with the job, and got the little extra from knowledgeable staff were important. The historical collective paradigm in elderly care needed to be abandoned in favour of one promoting more individualism. Fundamental was the courage to ask the older person what was important and dared to follow through to “Give power to the older person to decide what care to be given”. Conclusion: Organisational conditions affect unit leaders’ ability to succeed in the implementation of the work. Further studies are required regarding the nature of the support that the unit leaders need to succeed in their work.


Introduction
This article focuses on unit leaders' perspectives on a meaningful daily life for older persons in need of munici-pal care and is part of a larger action research project [1] initiated as a result of reported shortcomings in Swedish elderly care.The government introduced new national guidelines for elderly care, which included core values and local guarantees of dignity that highlighted the need for dignity, well-being and the organisation of the older person's daily life, so it is perceived as meaningful to them [2].Elderly care in Sweden is the responsibility of the municipalities and consists of home help service, nursing home care and home care in ordinary homes.The government gave each municipality the responsibility for the creation of its own guidelines, local guarantees and for the implementation of those guidelines.
Unit leaders play a crucial role in all health care organizations when guidelines are to be implemented.They affect both the quality of the care and the working environment [3].The changes that have occurred and are taking place in elderly care have resulted in complex organisations, instability and uncertainty that must be addressed [4].In addition, the number of leaders in elderly care has declined leaving fewer that are responsible for a larger number of staff.Staff education has also been questioned [5] and with inadequate skills, there is a risk that national and local targets for health care will not be met.
When introducing guidelines in elderly care, there is a need for shared visions among those working there.Hersey and Blanchard [6] state that once a leader has clarified and shared the vision, they can focus on serving and being responsive to the needs of the people with the understanding that the role of leadership is to remove barriers and help others achieve the vision.According to McCormack & McCance [7], the visions are the desired outcomes for person-centred practice stem from a therapeutic environment where the decision making is shared, staff members work collaboratively, leadership is transformational and there is support for innovative processes.
How leaders perceive relationships within the team and the impact of these relationships on practice is critical to the way that an effective practice context is created [8].Leaders' attitudes influence how they administer, which will affect the staffs' possibility to implement the changes necessary to create meaningful daily lives for older persons.
There are few studies on perceived meaning-in-life among older persons receiving home care, but studies from those receiving nursing home care show that it is significantly associated with the physical, emotional, social, and functional well-being quality of life dimensions [9].What constitutes a meaningful daily life for older persons, from the perspective of the older person, the relatives and the enrolled nurses, has been reported in the action research project [10]- [13].However there is a lack of knowledge from the leaders perspective on what constitutes a meaningful life and how it can be created for older persons receiving municipal care.The aim of the present study was therefore to describe unit leaders' experiences about what constituted a meaningful daily life for older persons receiving municipal care and which opportunities and obstacles might exist.

Design
The study was part of a larger action research project and combined the approach of Participatory Appreciative Action Reflection (PAAR) [14] and qualitative methods.The project aimed to seek opportunities and obstacles for the development of a meaningful daily life from the perspective of the older person by working together with them, their relatives, staff and leaders.Another aim was to use these data to formulate core values and local guarantees of dignity [1].There were 20 repeated interviews in the form of reflective conversations with nine leaders.The leaders provided their analyses and reflections on what had been said regarding a meaningful daily life for older persons.Finally, an analysis of the data was performed by the researcher, based on a latent content analysis [15].The regional Ethical Review Board in Uppsala approved the research project (Reg.No. 2011/009).

Participants
Recruited from one municipality in Sweden was the chief manager responsible for developing elderly care and leaders from five randomly selected nursing homes (n = 5) and three home care units (n = 3).A list of the nursing homes and home care groups based on the results of a user survey that rated the quality of the eldercare as favourable, average and low was used [16], to achieve variation [17].The three home care units had received favourable, average, and low ratings in the user survey; among the nursing homes, two received favourable ratings, one had an average rating and two had low ratings.The leaders held leader positions at each unit and were responsible for the implementation of the guidelines as well as the core values and local guarantees at their units.There were seven women and two men with a mean age of 45 years (range 28 -50) that had worked as units leaders between two and ten years.

Data Collection
The research was built on a co-creation of data and knowledge, focusing on the leaders' experiences of how meaningful daily life is envisioned by older persons.Seven leaders participated twice and two on three occasions in interviews conducted by the author.The leaders chose the time and location of the interviews, and all were carried out in their office.
The repeated interviews were conducted as reflective conversations on what factors could be important for a meaningful daily life thus leaving the direction of the conversation open [18].The main questions were: what is a meaningful daily life for an older person, and what can be the opportunities and obstacles to a meaningful daily life.The interviews were digitally recorded and transcribed verbatim.The leaders read the transcriptions before the second and third interview; then together with the interviewer provided their analyses and reflections on the content of what had been said regarding a meaningful daily life.In the second and third interview, follow-up questions were asked such as: what thoughts have you had about this since the last time we met, and do you remember what you mean by that.These conversations were also recorded and transcribed verbatim.

Analysis
To analyse the data a qualitative content analysis was performed in steps [15].The author first read the transcripts several times to acquire a general sense of the whole.Meaning units related to the same central meaning and relevant to the aim of the study were identified.The meaning units were then condensed into a description close to the text to grasp the manifest content.In the next step, the underlying meaning of the condensed meaning units was interpreted to determine the latent content, which was then coded.The codes were then compared and checked for differences and similarities; after which they were sorted into subthemes and five themes.The latent content in the themes was summarized and an overall theme emerged that described the leaders' experiences of what creates a meaningful daily life for older persons.The research group repeated the examination and discussion of the results during the analysis to ensure the trustworthiness of the data analysis and establish the best form for presentation.

Results
The leaders' experiences and reflections over what constitutes a meaningful daily life for older persons receiving municipal care were interpreted and five themes emerged: Routines and habits are important for a meaningful daily life, Have the possibility to feel independent, Familiarity with the job and that little extra promotes meaningful daily lives, Community creates a meaningful daily life, and Understanding and accepting the history of elderly care.
The themes constitute the unit leaders' perspectives of meaningful daily lives for older persons and the opportunities and obstacles that could exist.To give power to older persons over what care to be given was seen as a goal.The older person and the team around them working together would develop a care plan based on a shared vision on what a meaningful daily life was.Routines and habits were important as was the ability to feel as independent as possible.Knowledge and a good familiarity with the job, doing that little extra and a feeling of community were considered to be significant elements.The leaders felt elderly care should leave the collective thinking paradigm behind and strive for more individualised care.A place to start this process was to come to terms with the history of elderly care.

Routines and Habits are Important for a Meaningful Daily Life
The leaders saw an opportunity for meaningfulness with routines that meshed with the habits and needs of the older person.For example: the importance of continued training to maintain or regain lost functions, being able to eat what the old person preferred, and having surroundings in a familiar manner.The leaders could see the necessity of good working routines but a degree of flexibility was important to ensure some individuality and opportunities for spontaneity.

"We must have routines, but we can't create-your life should not be lived from our routines instead it's
what's around your life that we set up our routines for, so that it will be safe and secure and function.You should be able to wake up in the morning and think; it would be really fun to go and take a look at the castle.But we can't have routines for that.But we can have routines for free time so that we can do it." Knowledge of the older person's life story is an important key for shaping the routines around them.The leaders felt communication with older persons and their relatives would enhance their ability to individualise routines and create meaningfulness.

Have the Possibility to Feel Independent
A meaningful daily life from the leaders' perspectives was the ability of the older person to manage on their own and take care of themselves with as little help as possible.The leaders felt it was important if the older person was able to do things like: get out of bed, perform their own personal hygiene, dress and go to breakfast.The leaders also expressed that a meaningful life with dignity could be created by decreasing the staffs' physical presence as much as possible.With the use of security alarm systems, safety and security can be maintained without stifling older persons' freedom.
"Meaningfulness and dignity can be created without our presence, take for example a security alarm, just by having it leads to an increased independence." An opportunity for a meaningful life could be missed if the older person is prevented from living as they are accustomed because the staff considers the life style peculiar.
"Sometimes we can wrinkle our nose when we meet people that have chosen to live a life we think is strange.We shouldn't sit ourselves in judgement over that.It is also dignified to let people live the life as they have lived, even if it doesn't conform to our model." The leaders saw it as an opportunity for a meaningful life when their staff was able to interact with the older persons or their relatives and encourage them to do as much as possible for themselves.Obstacles occurred when the staff had difficulties communicating with the relatives and getting them to cooperate.There were also situations when the leaders felt their staff became locked in their routines and did not take advantage of the relatives' wishes to be involved in the care.

Familiarity with the Job and that Little Extra Promotes Meaningful Daily Lives
The leaders often reflected in the interviews on the importance of having staff that know what to do.To create meaningful daily lives it was important with both theoretical and clinical knowledge.It was also important that the knowledge was used effectively and in a dedicated manner.The leaders talked about a familiarity with the job among the staff, which can be very difficult to teach.
"Some personnel just do it right and I don't think it's only something they have in them, rather it is an ability all people can cultivate in different ways, but can be difficult to teach.As such we can find ourselves in a situation where it is demanded that I appear, behave and relate in a certain way-that conveys a form of dignity, everyone can relearn." All the leaders saw an opportunity for a meaningful daily life when the enrolled nurse felt a sense of responsibility for the older person and took pride in their work.Furthermore creating meaning in daily life is not only about what is done on a daily basis, but when something special is done."To do that little extra." "Yes, a person thinks that all this is so special.A person thinks these small things aren't anything.To have the ability to eat and drink.That these basic things work.And if there is some problem with some of these basic things, that they be remedied." Opportunities for a meaningful daily life could be found in the staffs' dedication to the older persons.They reflected over the importance of getting to know the individual staff members and the most effective way to work with and lead them on a more personal level.
"A person that thinks it is fun to go to work.A person that thinks it is fun to meet the elderly in the morning: wonder what mood that pensioner is in today.What shape are they in today?What can we do?And that's in your genes in some way.I can't explain it.It is fantastic.And then there are those others that know they have to do certain things.But only because there are written routines." According to one leader, when the staff use themselves as a tool in body and mind it could be an opportunity to create meaningfulness for older persons.But it could also turn into an obstacle if the staff member was having a bad day.
"The body as a tool when I work.And if I should feel so bad that I can't manage that role, I need to stay home sick that day.If I am sad and depressed and can't leave it behind me when I walk in, it can't be allowed to spread, because if it does then the one laying in the bed will be infected." The leaders also saw it as an obstacle when they as a leader did not dare to admit that some staff members were locked in the routines and were unable to remove their own values and expectations from the situation.
"But if we don't dare to admit that rather many of the older staff especially, have worked a long time in elderly care, then our efforts will fail, how should we continue working to bring about meaningfulness?"

Community Creates a Meaningful Daily Life
The feeling of community was considered important to create meaningful daily lives for older persons and the leaders reflected on staff that took time to for example sit down and drink coffee together with them.
"At a doctor visit-accompanying with a doctor visit-that a person takes their time and sits down at the clinic and drinks a cup of coffee together.That's important." Another opportunity for a meaningful daily life was when the staff creates alliances with older persons and relationships develop that lead to a feeling of community.The leaders also thought to achieve a meaningful daily life, the relatives should have increased involvement in the care of the older person.An obstacle arose when the staff had difficulties getting the relatives to cooperate.
"It is difficult to accept.An example is that it is difficult to accept criticism.Eh-em… I have many co-workers and enrolled nurses that have a hard time listening to relatives." One leader also pointed out that it was important not to pass judgement on the relationship between older persons and their relatives as there may be things in the family history they are not aware of.This leader also emphasized that the older persons were not complaining but instead felt sorry for the staff.
"It is the relatives and the older persons that say to me sometimes; yea, it hasn't really been so good, I must talk to you about it.But, you can't blame the staff because they are so hard working and do the best they can.And you have to feel sorry for the personnel."

Understanding and Accepting the History of Elderly Care
According to the leaders one place to start with was to try to understand the history of elderly care and accept it.They described how important it was to remember how it was previously and which guidelines governed the care.
"Our history influences us greatly.With the 1992 reform, long-term-care moved with all of its routines into another house that perhaps didn't look much like a hospital setting, but we took everything else with us.If we admit that, we can put our efforts into where it's seen the most." With the acceptance of the history and changes within long-term-care the leaders felt they could understand why the staff sometimes acted as they did and could better initiate solutions and help support the staff to create meaningful daily lives for older persons. "

And if we don't admit that it is so, then we continue without paying attention to the past into something new. To me that's dangerous. We must bring the history with us, we must dare to admit that that's how it was. It is first then we can identify: what's gone wrong. It has gone wrong for a person that shows clear tendencies of working undignified-as per definition dignity-however that should be. A person must look at that: why is it so?"
The history is permeated by collectivism.Collective elderly care became an obstacle to individualised care.The leaders felt that with this history there was a risk that older persons could lose their dignity and the staff might interact accordingly.Another obstacle for a meaningful daily life was when the older person lost in the collective whole was a subject to depersonalized waiting.
"There are nine people in a group, it's clear that of those nine there is someone that wants to sleep longer and another that likes to go up earlier.So there is a naturalness in it.But if you think about every morning here, Monday thru Friday there are three staff that should help nine people.And then some get help first and some get help last." The question that needed to be reflected on as a team was: how to approach the concept of meaningfulness, dignity and individualised care.There is the experience of meaningfulness and dignity; there is no real recipe or measurement that will apply to everyone.
"The knowledge part is the easiest part, to increase knowledge.The difficult part I think is to twist it and achieve individualisation.Nursing homes are per definition a collective solution for those that don't manage to live at home.It is a collective solution, but we must try to individualise the entire collective solution."

Discussion
This study highlights five areas that are important to create a meaningful daily life for older persons receiving municipal care.To start with the leaders felt it was important to be in agreement with what a meaningful daily life was for the older persons, and together with all the stakeholders find a common solution.A balance was needed in the daily routines that gave the older person the ability to feel as independent as possible.Familiarity with the job and the staff knowing what to do was important as was doing that little extra and creating a feeling of community for the older persons.Accepting the history of elderly care and abandoning the old doctrine of collectivism was considered necessary in order to develop care based on the new guidelines.The leaders felt that much is based on the vision for elderly care; to have the courage to ask the older person what is important and then dare to follow through to: "Give power to the older person to decide what care is to be given".
The leaders view on creating a meaningful daily life differs somewhat from the results of the larger project [1] as they were more focused on the staffs' involvement.The older persons living in nursing homes talk about having space to be themselves, a sense of belonging and a feeling of security.Obstacles to a meaningful day were the absence of space and feelings of insecurity.There was a longing for something to happen [10].Older persons living at home with homecare actualise their own meaningful daily life by striving to maintain their routines and habits, and live their lives as normal as possible.They struggled between handling the increased demands and accomplishing everyday activities.The older persons created a reciprocity and collaboration with the staff to achieve a meaningful daily life.The ongoing dialogue between the older person and the staff becomes "the glue".Furthermore, for a meaningful daily life it was important to have a sense of belonging, a sense of closeness and togetherness, to retain previous relationships as well as establish new ones [11].To maintain routines, habits and an everyday rhythm filled with meaning in a home like environment and in community with others, relatives felt a partnership was needed between the older person, their family members and the staff.[12].Enrolled nurses create a meaningful daily life by being perceptive and responding accordingly to the older person.They read the older person in order to judge how the person is feeling, adapt to their daily life and share it with them [13].The different stakeholders seem to share the same values regarding space to be yourself, habits and routines and a feeling of community to create a meaningful daily life for older persons.However the leaders differed somewhat with the other stakeholders in that they reflected over the importance of having a common vision, understanding and accepting the history and the individualisation of the collective solution in elderly care.This difference is understandable as they were the ones responsible for implementing the guidelines in their units and were more focused on how to lead to succeed with the work.However to succeed they might be more aware on their own role as leadership seems to be one of the key factors for implementation success.Their ability to create a culture receptive to evidence-based knowledge seems to be essential, together with their ability and willingness to provide feedback and to lead by own good example.A strong and clear leadership does not by it selves create changes.A supporting organization and a favorable culture also affect the process [19].
The results show that a common vision of a meaningful daily life is needed in order to shift the power regarding care to the older person, which is in line with person centred care that highlights a need for shared values [20].Hersey and Blanchard [6] point out that when everyone supports the organizational vision it creates a deliberate focused culture that drives the desired outcomes.This is in accordance with McCormack & McCance [7] and their idea of the shared visions being the desired person-centred outcomes of: satisfaction with care, involvement with care, feeling of well-being and creating a therapeutic culture in which decision-making is shared, staff relationships are collaborative, leadership is transformational and innovative practices are supported.
The leaders in this study felt that understanding and accepting previous history, guidelines and practices was important.They saw the history permeated by collectivism that could become an obstacle to individualised care.The leaders felt that with this history there was a risk that older persons could lose their dignity and the staff might interact accordingly.Another obstacle was when the older person lost in the collective whole was a subject to depersonalized waiting.This can be seen as a collective memory existing among the stakeholders, one that is influenced by the history of elderly care, with a common knowledge [21] or shared experienced [22] within a group.The collective memory and the values it encompasses are shaped and reshaped by different processes and is influenced by various factors and actors [23].In this dimension will it be important that the leaders choose the right tools for the implementation.Further investigation is needed on how to influence a new collective memory among all stakeholders where the older person has more power in their care.
Care for older persons in Sweden underwent significant changes during the 1990s when there was a reduction in the number of public nursing homes.Successive reductions in services for the majority of older persons and a pronounced trend to first help the oldest of older persons and those most in need of help was evident.This in turn has meant that persons who live in public nursing homes have become more dependent on health care efforts.Simultaneously, municipal problems with financing public care have increased.There seems to be a need to adopt a caring approach geared to meeting the needs that create meaningful spaces and places with person-centred care, and is something that requires further investigation.McCance et al. [24] show that patients and staff recognize moments of person-centeredness but there are long periods where person-centeredness is not the dominant focus in daily life.
The organizational conditions that these leaders have will affect their ability to succeed in the implementation of the work.There is a lack of knowledge on how managers can promote the implementation and probably not fruitful to study characteristics of the leader without taking into account the organization where the person works and its cultural climate.Success with implementation seems to be depended on the interaction between these three components [20].There are often short-term solutions in the development of elderly care, therefore whatever resources the leaders have available must be used wisely.Despite hard savings in Swedish elderly care that have led to "slim downed" organizations, Larsson [25] explains in her thesis that there is room for development within the majority of the organizations.This requires however that the unit leaders prioritize the question of what is important, create space for creativity and flexibility, develop shared visions, and create time for learning and reflection.

Methodological Consideration
In action research it is important that the participants take part as co-researchers [26].In the present study, the leaders can be seen as co-researchers in the collection of data.Thus, they were able to change, delete or advise shortcomings as well as add to the data.To achieve credibility in the study, in the repeated interviews the authors continually discussed and reflected together with the leaders.The results contain direct quotations, which give the reader an opportunity to judge the credibility.To strengthen credibility the same opening question was asked in each interview regarding what a meaningful daily life is for an older person [11].The number of leaders who took part could be considered small.According to Sandelowski [27], the sample size in qualitative research should be large enough to achieve a variation of experiences and small enough to permit a deep analysis of the data.A strength, however, could be the repeated interviews, which totalled 20.The leaders considered participation in the research valuable and considered it to be a positive experience.

Conclusions
When implementing guidelines to create a meaningful daily life for older persons, the leaders in this study expressed that there was a need to start with a shared vision based on the guidelines.Understanding and accepting the history of elderly care are necessary if change is to occur.Routines and habits were important for the older persons as was the ability to feel as independent as possible.Knowledge and a good familiarity with the job, doing that little extra and a feeling of community were considered to be significant elements.The leaders felt that much was based on the vision for elderly care; to have the courage to ask the older person what was important for a meaningful daily life and then dared to follow through "Give power to the older person to decide what care is to be given".
The leaders felt elderly care should leave the collective paradigm behind and strive for more individualised care.The organizational conditions that these leaders will affect their ability to succeed in the implementation of the work.Further studies are required regarding the nature of the support that the unit leaders need to succeed in their work.