Being present in caring encounters : a relational perspective on autonomy for older persons in municipal home help services

The care of the old in Sweden and worldwide is developing towards an “aging in place.” Older people in Sweden are expected to remain in their own homes supported by municipal home help services. This development has entailed that older people’s need of support as well professional carers workload has increased. The older persons need of support is assessed by care managers, and research shows that they are in an exposed position when applying and often do not have their preferences met. In addition research also shows professional carers’ difficulties in the care of the old and their need for support. The suggestion is a relational perspective in the care of the old to promote older persons’ autonomy due to their increased dependency. Up until now there has been little research into older peoples’ experiences of autonomy in municipal home help services. This thesis was therefore considered important to enhance knowledge and understanding of older persons’ and their professional carers’ lived experiences in everyday life.

The overall aim of this thesis was to develop knowledge of older persons’ opportunities to make independent decisions and to consider how professional carers can help them to improve their independence. This thesis compromise four studies (I-IV) and has a qualitative and a live world approach. In order to deepen the understanding of the meaning of older persons’ and professional carers’ experiences they were followed over time. Interviews have been conducted with older persons and professional carers before, during and after the professional carers participated in an educational programme. Data was analysed I-IV with a phenomenological hermeneutic method.

The aim of study I was to illuminate the meaning of older persons’ dependence on caregivers’ help and of their opportunity to make independent decisions. The findings reveal that they are either struggling to make independent decisions or resigning themselves to not being able to do so.

The aim of study II was to illuminate the meaning of carers’ experiences of being in caring situations when a conflict of interest arises with the older person receiving care. The finding reveals that they are ambivalent in conflict situations, weighing older persons’ right to self-determination against external demands.

The aim of study III was to illuminate the meaning of older persons’ independent decision making concerning their daily care. The findings revealed how they live with uncertainty as to how to relate to independence and dependence with regard to themselves and others, and how they try to comprehend everyday life.

The aim of study IV was to illuminate the meaning of professional carers’ experiences of supporting older persons’ to make independent decisions in caring situations. The findings revealed that they are being torn between respecting independence and dependence and it is therefore complicated to support older persons to make independent decisions.

A deeper understanding was reached considering the findings I-IV and disclosed; waiting for others to comprehend their everyday life, torn between external and internal demands and striving for interdependency in caring encounters. The conclusion of this thesis is that a relational perspective on autonomy as a shared-decision making could be valuable in the care of the old to enable for professional carers to support older persons in making independent decisions. The implication for practice is a person-centred care in the care of the old to promote a relational perspective on autonomy.

List of scientific papers

I. Breitholtz, A., Snellman, I., & Fagerberg, I. (2013). Older people's dependence on caregivers' help in their own homes and their lived experiences of their opportunity to make independent decisions. International Journal of Older People Nursing. 8(2), 139-148.
https://doi.org/10.1111/j.1748-3743.2012.00338.x

II. Breitholtz, A., Snellman, I., & Fagerberg, I. (2013). Carers' ambivalence in conflict situations with older persons. Nursing Ethics. 20(2), 226-237.
https://doi.org/10.1177/0969733012455566

III. Breitholtz, A., Snellman, I., & Fagerberg, I. (2013). Living with Uncertainty: Older Persons' Lived Experience of Making Independent Decisions over Time. Nursing Research and Practice. 2013, 403717.
https://doi.org/10.1155/2013/403717

IV. Breitholtz, A., Snellman, I., & Fagerberg, I. Professional carers torn between respecting older persons’ independence or dependency. [Submitted]