Being altruistically egoistic-Nursing aides' experiences of caring for older persons with mental disorders.

Older persons with mental disorders, excluding dementia disorders, constitute a vulnerable group of people. With the future international increase in the older population, mental disorders will increase as well, thus entailing new challenges for their caregivers. These older persons often remain in their own homes, and in Sweden they are cared for by nursing aides. With little previous research, an increased workload and facing new strenuous situations, it is important to make use of the knowledge the nursing aides possess and to deepen the understanding of their experiences. The study aimed at illuminating the meaning of caring for older persons with mental disorders as experienced by nursing aides in the municipal home help service. Interviews with nine female nursing aides were performed and analysed with a phenomenological hermeneutical research method inspired by the philosophy of Paul Ricoeur. Being altruistically egoistic emerged as a main theme in the nursing aides' narratives. The nursing aides' experiences could be interpreted as a movement between being altruistic and egoistic. The findings revealed a continuous distancing by the nursing aides and their struggle to redress the balance between their altruistic and egoistic actions. Caring for these older persons constitutes a complex situation where distancing functions as a recourse to prioritize oneself and to diminish the value of caring. The study suggests that an increased knowledge base on older persons with mental disorders, followed by continuous supervision, is necessary for the nursing aides to improve the quality of the care given.

The older population is increasing, internationally (National Institute on Aging, 2007; United Nations, 2008) and in Sweden (Statistics Sweden, 2011). Older persons are and will be affected by several disorders, frequently including mental disorders (Mechakra-Tahiri, Zunzunegui, Preville & Dube, 2009; Olivera et al., 2008), even if dementia disorders are not taken into account (Martinsson, Wiklund-Gustin, Fagerberg & Lindholm, 2011). The increase in the older population implies changing needs, indicating that many health care systems will face challenges regarding the care of persons with mental disorders (Clinton, 2007). The organizations providing care and service to the old vary between countries, depending on the structure of the health care system and its finances. Older persons with extensive needs express the wish to continue staying in their own homes (Ryan, McCann & McKenna, 2009), and several countries experience a current or continuous increase in informal and formal care service provision to older persons in their own homes (Australian Institute of Health and Welfare, 2007; Klein, 2008; Qiu et al., 2010). Regardless of the international differences in care providers, the increase in older persons’ needs for health care and support is applicable to all countries. Swedish governmental reforms have led to more care and service being continuously provided in ordinary housing by nursing aides or enrolled nurses (National Board of Health and Welfare [NBHW], 1996, 1999). Older persons remaining in their own homes can be granted support from the municipal home help service in accordance with the Social Services Act (SFS, 2001, p. 453). The support varies depending on the needs of the old and is provided to facilitate daily life e.g., personal care, cleaning and purchasing groceries. The National Board of Health and Welfare (NBHW, 2011) states that there is an increasing number of older persons receiving home help service, and that the number of staff has decreased at the same time. This implies that the workload for nursing aides has increased, and they may consequently face situations that require more knowledge on a wider range of subjects.

Studies on older persons’ perceptions of home help service in Sweden indicate that those with severe deficiencies and needs are the most dissatisfied (NBHW, 2011). The current situation for older persons with mental disorders is scarcely studied, and questions have been raised whether they are provided with adequate home help service or not. Previous studies have focused on nurses’ experiences of caring for older persons in community psychiatric care (Hellzén & Asplund, 2006), their encounters with violence (Carlsson, Dahlberg & Drew, 2000), informal caregivers’ experiences of living with relatives with mental disorders (Chang & Horrocks, 2006; Tranvåg & Kristoffersen, 2008) and views of staff caring for older persons with depression (Hassall & Gill, 2008). Studies of municipal care include a wide range of phenomena, such as ability to assess older persons’ needs (Olivius, Hallberg & Olsson, 1996), stress levels among informal caregivers (Carretero, Garces & Rodenas, 2007) and registered nurses’ experiences of caring (Gustafsson, Asp & Fagerberg, 2009). Registered and enrolled nurses have consequently been the focus of several studies in municipal care, focusing on daily activities (Nilsson, Lundgren & Furaker, 2009), experiences of working with the old (Häggström, Mamhidir & Kihlgren, 2010), expectations (Karlsson, Ekman & Fagerberg, 2008) and experiences of violent encounters (Åström et al., 2004). However, nursing aides have rarely been the subject of investigation on their own, even though they frequently encounter older persons in their own homes. To increase the quality of the care provided to older persons in ordinary housing, it is important to bring awareness and new knowledge on all aspects of the care. Studies have shown that the increased workload and pressure on the nursing aides results in their resigning from their jobs (Flackman, Sorlie & Kihlgren, 2008) and that personnel in municipal care of the old are frequently on sick leave (Sandmark, Hägglund, Nilsson & Hertting, 2009). To maintain continuity in the care of the old, it is important for nursing aides to feel encouraged in their work and to be provided with sufficient organizational resources and support. As nursing aides are frequent care providers to older persons with mental disorders in their own homes, it is important to illuminate how they experience caring for them. This deepened understanding of how they experience working with older persons with mental disorders may, when noticed by the superiors and implemented in the organizations, in turn increase the quality of the care provided and also facilitate improvement of their own situation.

Aim

The aim of this study was to illuminate the meaning of caring for older persons with mental disorders, except dementia, as experienced by nursing aides in Swedish municipal home help services.

Methods

In order to explore nursing aides’ lived experiences of caring for older persons with mental disorders in municipal home help service the study had a lifeworld approach. The lifeworld is the world as it shows itself to our consciousness and where phenomenology states that our consciousness is aiming at something that involves a meaning; hermeneutics states that this something is not given in advance but has to be interpreted. Hence, there is no understanding without explanation and therefore phenomenological hermeneutics was used in this study. The objective in phenomenological hermeneutics is to describe the phenomenon and increase the understanding of being in the world (Lindseth & Norberg, 2004). In this study, we strive to understand and explore the meaning of nursing aides’ lived experiences of caring for older persons with mental disorders, except dementia, in municipal home help services.

Setting and participants

The study took place in the municipal home help service in two rural and one urban district in Sweden. Some of the nursing aides were part of the general staff and visited older persons both with and without mental disorders, while others only visited older persons with mental disorders. Mental disorders is in this study a generic term referring to, e.g., affective, psychotic and anxiety disorders, but excluding dementia disorders. The encounters with the older persons varied from single or recurrent daily visits to visiting one older person for the entire day.

The study had a convenient sampling, all nursing aides eligible (nine in total) were included. The selection of the nursing aides was made together with the departmental heads at six organizations. Criteria for selection were: being employed as a nursing aide, having experience of caring for older persons (age ≥70) with non-dementia mental disorders and with varying length of experience in the home help service. The nursing aides’ work experience in municipal settings ranged from 8 to 41 years with an average of 25 years. The nursing aides were all Swedish-speaking but three of them had another European native language.

Data collection

The source for data collection was interviews, as lived experience of caring for older persons with mental disorders was to be studied. The head of each organization granted permission for the study and distributed inquiries of participation to nursing aides that met the inclusion criteria. The inquiry contained information about the study, procedure and that participation was voluntary. After receiving the inquiry, the nursing aides were phoned by the interviewer (GM) who explained the study more thoroughly. The voluntariness was again highlighted and although they were given another opportunity to decline to participate, they all agreed. The nursing aides decided the time and place for the interviews, and all interviews were conducted at their work places. At the interview, the objective for the study and the procedure for audio recording and confidentiality were explained, and the voluntariness was elucidated. The nursing aides were informed about the possibility to withdraw from participation at any time during or after the interview, and thereafter all nine nursing aides signed a consent form.

The nursing aides were asked to narrate situations when they had encountered and cared for older persons with mental disorders. The interviewer then asked clarifying questions to improve understanding or to encourage the nursing aide to narrate further. The interviews lasted from 40 to 75 min and were transcribed verbatim by the first author. All personal information was replaced with codes, and the codes and transcripts were kept at different locations at the university to ensure confidentiality. The interviewer had no established relationship with any of the included nursing aides prior to the study.

Analysis

This study used a phenomenological hermeneutical method, inspired by the philosophy of Ricoeur (Lindseth & Norberg, 2004), for the analysis. The method is suitable for interpreting interview texts in order to understand the lived experience of the nursing aides and to explore the meaning. The dialectic in the analysis moves from understanding to explanation and then from explanation to understanding or comprehension (Ricoeur, 1976). The first step in the analysis was the naïve reading where the whole text was read to grasp a first understanding. The next step was the structural analysis where the text was read again and divided into meaning units, which by thorough analysis were condensed, Table I, and abstracted to sub-themes and themes. Finally, in the comprehensive understanding, the themes, sub-themes, the naïve understanding, the authors’ pre-understanding and relevant literature were brought together to create a deeper or new understanding.

Table I

Example of meaning units and their condensations that emerged from the nursing aides’ narratives.

Meaning unit		Condensation
IPa:	[…] and he was angry. He was really angry so when we were about to leave he knocked his fist on the cupboard, like, exactly 20 centimetres from my head. Then I wasn't happy …	Keeps a straight face and takes no notice despite punches aiming at the nursing aide. Leaves, exhales and considers what the older person was really aiming at
Ib:	What did you do?
IP:	I kept a straight face. And let, took no notice and said thank you and goodbye … we were leaving anyway.
I:	How did it feel?
IP:	When you come out, then when you come out I say, Oh Christ I say! Ah, I thought he would punch me, but then my colleague who had more experience told me that he would never do that. No. I think he would probably not have done that. No, he was just mad. And then it is better if he punches the cupboard than me, and probably he thought so as well.
IP:	[…] We have had a woman with bipolar disorder and everything is pretty OK when she takes her medicine as she is supposed to, but she got this idea that she would stop taking the medicine, so she did. So now she is on a roller coaster and one day really on the top only to fall flat the next day, all the way to the basement, you know. She drags herself from the bed, to the kitchen table, and back to bed and that is how she spends the entire day. In the best of cases you can motivate her a tiny bit, and in the very best case you can maintain a normal level but it, it happens very rarely … and that you just have to endure. Because you can't do that much. There are many times people are really timorous, you really have to endure, it is not always that easy, because you want so much and can do nothing … when there is nothing you can do about it …	Often wants to do a lot but can sometimes do nothing. Has to endure and understand that the older person is exhausted
IP:	[…] I usually say that “You, now it's time to take a shower, because now you're dirty. Now it smells” … You can start the day before … “I, you know, I will help you! I can wash your hair, do what you can't and then you can do what you can.” “Yes”, he says. And then you come the day after, “Yes, so you know that you should take a shower today.” Yes, we can wait for a minute, because then he has the cleaning at the same time, so I usually say, “Yes but, I can clean a bit and then you can take a shower.” And it usually is OK … and then he sort of helps me in the shower, with washing the hair cause he can't reach with his arms … dry him and … and then he goes to bed. [Laughter] So, then you may be allowed to help him with his clothes after a while, so he can do things at his own pace. It usually goes OK … sometimes not, but most often.	Mentions an activity early to make the older person think positively about it. Lets the older person do things at his own pace

IP, interview person

I, interviewer.

Ethical review

This study was revised and approved by the regional ethics board (Dnr 2008/345). When interviewing nursing aides, the interview might entail feelings of insufficiency or feelings of being judged. On the other hand, the interviews gave them the possibility to reflect upon their values and thoughts about older persons with mental disorders. The interviews may have encouraged a reflection about the work performed and in that way contributed to personal development. The interviews may also have led to increased knowledge of competence among nursing aides and increased awareness about what they can improve in their work. The benefits were considered to outweigh the risks in this study.

Findings

Naïve reading

In the naïve reading, being with older persons with mental disorders meant being present here and now. The nursing aides acknowledged the older persons and showed them that they took the time to be there even if time was not permitting. They adjusted their work according to the older person's daily mood, strength or spirit. In the situation with the older person, the nursing aides distinguished between their professional and personal lives and chose to act professionally. They looked intently at each situation and acknowledged dangers and threatening situations for themselves. The line between threatening and manageable situations was subtle and often involved a decision whether to stay or go. In threatening or dangerous situations, the nursing aides’ own safety was prioritized above caring.

To work for and with the old, to have to fight for their desires and to make their desires known was frustrating. The feeling of affinity with the older person could be strong; the nursing aides regarded the old person as a fellow being and considered the person rather than the disorder. They felt helplessness if the disorder could not be treated or cured. They experienced contradictory feelings of joy when meeting the person, but also fear over the prospect that the older person could act on the basis of their own reality. A close relationship led to difficulties in drawing the line or in distinguishing between one's personal and professional life.

Structural analysis

In the structural analysis, the main theme “Being altruistically egoistic” emerged. The main theme comprised four themes (Putting oneself first, Acknowledging the older person, Enduring the unknown and Striving to make the best of the situation) and 17 sub-themes, as shown in Table II.

Table II

Sub-themes, themes and main theme that emerged from the nursing aides’ narratives.

Sub-themes	Themes	Main theme
Setting boundaries between personal and professional life
Emanating from oneself and one's own experience to become calm and secure in the situation	Putting oneself first
Leaving the visit behind and moving on to the next
Protecting oneself
Being sensitive to the older person's condition, receptiveness and mood
Allowing the older person to participate in the decisions
Fighting for the older person's needs in the organization	Acknowledging the older person
Considering the older person's safety		Being altruistically egoistic
Being a fellow being
Bearing melancholic feelings
Facing another reality
Bearing powerless situations	Enduring the unknown
Being bothered by and in the situation
Trying to be professional as a nursing aide
Being clear and straightforward in one's way of working	Striving to make the best of the situation
Maintaining the older person's habits
Making own goals for the visit

Being altruistically egoistic

The main theme “Being altruistically egoistic” meant that the nursing aides prioritized themselves in situations with the older person but showed respect for the older person as a human being and as the owner of the home they entered. The theme implied a movement between being altruistic and being egoistic. When altruistic, the nursing aides worked with the older person's best in mind and were present and obedient to the older person's wishes and needs. Being egoistic meant that they endured situations that sometimes involved a feeling of resignation, in order to be able to continue with their work and move onward to the next person. The nursing aides built a work routine that created trust between themselves and the older person and thereby reduced anxiety. This meant that the nursing aides in any situations did what they considered would generate the best outcome for the older persons as well as for themselves.

The main theme comprised four themes, which in turn comprised a total of 17 sub-themes as demonstrated in Table II. The four themes are described in subsequent sections.

Putting oneself first

Putting oneself first meant being aware of oneself as a person, acknowledging and prioritizing oneself in the situations. It meant finding the strength to face situations intruding on one's privacy and situations where one needed to rely on the professional obligations. Furthermore, trying to distance oneself from the older person made it easier to not get too attached or engaged. To maintain one's privacy, a distinction between personal and professional life was made, and clear boundaries were set. When lacking formal knowledge on how to deal with situations, the own experience of previous situations both in personal and professional life was used. Reliance on the past and how earlier situations had been dealt with offered a calmness and security that was necessary in order to protect oneself. When emanating from self the own experience was used, and assumptions about how things were to be done when caring for older persons with mental disorders were made. It meant doing what one believed would lead to the best outcome for the older person.

…Then you have to try, or at least I do. I have no education in how to do it but I do it like that with him because I think I have got to know him and that you have to… slow down and really speak slowly… NA3

When relying on the professional obligations, one acknowledged what needed to be done in order to manage the workload. The pressure of work was used as protection so as to be able to leave situations even if not being finished with what needed to be done. In order to protect and prioritize oneself, one dared to leave the situation or visit behind and start over again with the next one, without reflecting too much about what had been left behind. Putting oneself first also meant daring to give precedence to the self and one's own safety in threatening and dangerous situations. It meant leaving the home of the older person when urged to do so or when one oneself was afraid or insecure. Putting oneself first meant prioritizing one's own safety before caring for the old.

Acknowledging the older person

Seeing the human being and not the disorder meant being sensitive to the older persons’ state of mind and changing the way of working accordingly. It meant doing nothing that would impair the relation or situation and being keenly aware of the older persons’ ability to accept new ideas and do nothing extra if not possible.

… then I put the potato peels in the coffee filter with the coffee grounds, and put them in a particular bucket that he keeps for compost in the basement, and then I usually … some days I rub his feet and … and so on if he feels like it. And chat a bit, yes, and then there is really nothing else he needs help with: “So if there isn't anything else you need help with I'll get myself ready to leave”, “Yes” he says. Sometimes there can be something else; if he has a good day then I can help him with his laundry and then he asks whether or not it's time to wash the towels, ‘cause he hasn't done it; he is a bit insecure and doesn't know when it's time and then I have to say yes or no. And then I check out, put on my coat, ask if I should lock the door, which he most often wants me to do. Sometimes he says “No, I'll do that”, but otherwise I just unplug his time clock and leave… NA3

Acknowledging the older person meant working with the older person in mind and letting them, or trying to make them participate in the decision-making. Encouragement or permission to let the older persons participate was upheld to every extent possible, when it did not involve danger to themselves or for oneself. Fighting for the older persons’ needs in the organization meant acknowledging what one felt needed to be done to improve the older person's situation or listening to the thoughts of the older person. Own thoughts about the older persons’ needs or expressed desires were brought to the attention of the organization. Feelings of frustration arose when fighting for the older persons’ needs in the organization without being shown understanding, positive feedback or approval.

Considering the older person's safety meant working with the older persons’ safety in mind and being attentive to the older persons’ health and needs. It meant acknowledging the older person and taking the responsibility of contacting superior care personnel when seeing something that required more help than one oneself had the authority or possibility to provide. Acknowledging the older person meant functioning as a fellow being, seeing the older persons’ needs and embracing their situation and state of mind. Acting as a fellow being meant being there in the moment, sitting next to the older person, listening and focusing on them and their well-being.

Enduring the unknown

Having to go through situations where the aim was to survive was to endure the unknown. The older person's melancholic feelings were passed on, and one needed to bear and endure them in order to be able to follow through with the tasks expected of oneself. It meant feeling helplessness and struggling with questions of whether or not one's efforts were sufficient. Some could release their emotions by discussing the issues with fellow co-workers while others bore and endured them by themselves:

…he can, he hears a lot of voices, so he talks a lot with the voices, and then I usually, most of the time he is very loud and he screams and shouts and so… and then I usually ask him if the voices are mean now. Because they can be mean, but sometimes they are nice, but sometimes they are extra mean, constantly saying “Go and sit down! Go to bed! Go!”, I mean the voices say that to him and then it is like, how should I say this, it feels tough in a way, when you see how hard it is for him… NA5

Enduring the unknown meant being aware of the older persons’ disorder and the impact it had on the person, as well as the incurability, and being powerless facing situations where there was nothing else one could do. It meant needing to endure the powerlessness and trying to make the best out of the situation and do what was in the best interest of the older person. Facing other realities meant encountering realities that did not correspond to one's own. The encounter was frightening and one reacted to the older persons’ expressions although neither wanting nor expecting to react. In order to stay in the own reality and continue on with the planned activity one needed to endure the unknown when encountering these different realities and manage the diverse feelings that arose from the meeting.

… ehm… and he saw people hanging in the trees and stuff like that, so the first time I remember, it was in the fall and then he says, “Do you see that person hanging in the tree there?” Then it was almost like I got the hiccups [laughing], before and then, before you, we had received reports about his persona and reality and so on: but still you experience this like Oh God!, so to speak, that you were obliged to watch and so but eh… NA1

Being self-conscious by and in the situation meant that situations involving an encounter with the different were bothering. It also meant that one needed to endure the troublesome feelings in order to follow through with the work one was supposed to do.

Striving to make the best of the situation

Striving for the best in any situation, for oneself and/or for the older persons meant trying to be professional, i.e., trying to work in a way that would be considered professional or in a way one had learned was professional. It meant trying to dress up in the “professional coat”—not to engage too much or show one's feelings, in order to be able to work and make the best of the situation.

… His son passed away. And it was hard because I knew his son as well and then it gets, it gets tough and difficult then. Then the co-workers have to comfort me when I cry [Laughing], because you can't sit there and cry when you come to help him and support him and so […] Well, then I sit and cry here at the office [Laughing] and then someone of the co-workers have to comfort me and then […] So then when you've been at his place there is always someone asking, “How did it go?” Well OK you say and then you cry a bit more. Then it usually is OK… NA4

Striving to do the best in the situation meant not complicating the work or worsening the older persons’ condition. It meant being clear and straightforward in communication with the older persons, so they would not get confused, worried or angry. In order to maintain a calm and controlled situation, one's efforts aimed at making it obvious to the older persons what was on the agenda and what needed to be done. To not render a more difficult working situation one tried, to every extent possible, to maintain the older persons’ habits, not to move anything from its ordinary place or to change anything that would complicate the older person's well-being.

…Yes, that was coaxing, I think, with, and just, some, well some things should be lying here and the watch there and things like that exactly, and if you touched that then he was really mad. Yes… And so on. He had woodpeckers under the bed and, yes, there were a lot of things like that… NA1

Making the best of the situation meant to establish one's own goals for the situation and the activity. Establishing own goals for the visit meant doing things not always appreciated by the older persons, but the activities were carried out in order to make the best of the situation according to oneself.

Comprehensive understanding and reflections

Caring for older persons with mental disorders, as experienced by nursing aides, involves an altruistic element implying a will to be there for the older persons, to show them respect and to focus on them. When caring, the nursing aides may emanate from a conscious, as well as an unconscious, desire to create a good life, where the purpose is represented by the most happiness for all. Aristotle proclaimed that doing a good deed differs from doing a good deed in a good way, but everybody facing an assignment strives to execute it in the best way possible (Aristotle, 1967). Ricoeur refers in his deliberation about ethics to Aristotle, agreeing with his thought about the good life being the profound end of the ethical intention and the object of our actions (Ricoeur, 1992). Aristotelian ethics have been further developed in present time by utilitarians such as R. M. Hare (1981). The utilitarian philosophy does not intend to provide a guide for how to act in the morally best way but presents an approach to life where every action performed for creating the most happiness is a morally good action. The philosophy suggests that our intention in every action should be to create the best resulting consequences for all. Hare separates two levels of our thinking where the intuitive thought when facing an ethically challenging situation is utilitarian, while the following analytical or critical thinking is more complex (Hare, 1981). This corresponds to the actions of the nursing aides; they seem to act intuitively on the basis of creating as much happiness as possible for themselves as well as for the older persons, hence a utilitarian approach. When asked about their thinking in certain situations, they apply a more critical approach and reflect upon whether the action indeed favoured the older person's autonomy and brought them happiness or if it was simply the easy way out.

The nursing aides’ actions were done in order to render a pleasant environment and a calm and satisfied older person, i.e., a pleasant situation for both parties. They performed, congruent with the utilitarian view of life, their tasks with good intentions. They respected the older person and tried to execute their tasks in the best way possible. But there is an obvious distinction between performing the task with good intentions and performing it in the best way. What represents a good life for the older persons or for the nursing aides differs, and the apprehension of something appearing good is very subjective. The nursing aides face the situations with good intentions but might, due to their own fear or insecurity or to the older persons’ behaviour, not always be able to perform their tasks in the way they intended. A previous study suggests that providing good care for persons with mental disorders means accepting them the way they are, not trying to change them, and that such acceptance may result in a positive change (Nyström, Dahlberg & Segesten, 2002). In the present study the nursing aides try to consider each caretaker's individual perception of a good life when caring for them. However, due to fear, insecurity and ignorance, the older persons’ individual needs and desires might be neglected.

The nursing aides’ effort to create the best situation possible for the older persons may reflect upon their own situation thus the altruistic element may also imply an egoistic element. Hence, the movement in the main theme becomes apparent. The egoism manifests itself in different aspects. It may function as recourse to facilitate putting oneself first and reducing the significance of caring, leading to the nursing aide daring to leave the situation without fulfilling the care aim. The nursing aides tried to every extent possible to not impair or complicate their working situation or the older person's condition. The findings indicate that they experience themselves as working in a precarious context and that they use a lot of their previous experiences when deciding on what to do in the situation they are facing. The importance of experience is not negligible; without their previous experience the nursing aides would be perplexed when encountering the older persons. They would possibly struggle to find the route that answers both to their moral thinking as well as to the consequences of their actions. Utilitarians have emphasized that we through experience learn what our actions will bring and that our moral thinking, as well as our wisdom, is dependent on that experience (Mill, 2001). Gustavsson (1996) suggests that nursing aides’ usage of previous experiences comes from a lack of theoretical education and professional knowledge. Gustavsson further suggests that the usage brings a deeper personal involvement and devotion to the old, which may form a heavy burden for them and lead to their resigning from their jobs. The nursing aides’ trust in their previous experience may be sufficient for some situations, but when facing recurrent challenges they may need more theoretical education in combination with their hands-on knowledge to maintain security in these situations and to feel encouraged to stay with their jobs. Also, their experienced insecurity may reflect upon the older persons’ actions and behaviours, thereby also increasing the older persons’ insecurity.

Interpersonal relations in caring can contribute to the progression of older persons with mental disorders as human beings (Barker, 2000) and in light of Barker's theory the nursing aides may worsen the situation by instinctively trying to distance themselves from the older persons. Such distancing may lead to an impaired interpersonal relation and may disturb the older persons’ progress. Hellzén, Asplund, Sandman, and Norberg (2004) suggest that the main goal when caring for persons who act provocatively is to see the person behind the visible expressions. However, caring for older persons with mental disorders as understood in the present study involves distancing, mainly to prevent attachment to or from the older person. This finding coincides with Määttä (2006), who found that distancing may serve as a defence for not becoming too engaged in the caregiver-patient relationship. In the present study it becomes apparent that distancing functions as protection for the nursing aides offering an opportunity to withdraw from threatening situations or from the need to share their own feelings. The fear of building a relationship with the older person, the insecurity and the distancing may be signs of compassion fatigue. Compassion fatigue, or loss of ability to care for the patient, may affect the caregivers when they experience themselves as not being able to help the patient. It appears due to secondary damages and involves emotional as well as ethical aspects (Forster, 2009). Lack of experience may lead to compassion fatigue (Yoder, 2010), which implies that the nursing aides may run a high risk of developing it. In order for the nursing aides to cope with the ethically challenging situations they encounter, they may use distancing as a possible way out. Barker (2000) suggests that distancing may obstruct the bridging between the caregiver and patient. Although possibly occurring intuitively, the distancing in the present study obstructs the nursing aides’ relation with the older person. The nursing aides may distance themselves from the older person due to insecurity about which role to adapt or because of a misbelief that professional equals being distanced. The distancing may also serve as possible recourse for the nursing aides to relieve their powerlessness and melancholic feelings and to disregard other realities encountered. This finding coincides with Lindseth, Marhaug, Norberg, and Uden (1994) where distancing was found as a result of the caregivers’ necessity to be protected by their professionalism, to not show personal vulnerability.

Altruistically, the nursing aides were attentive to when the older persons’ condition needed more help than they themselves could provide—and egoistically they were aware of when they needed to withdraw so as not to exceed their authority. Being a nursing aide in a municipal home help setting implies a lack of authority. Recognizing not being able to provide all the necessary caring or nursing may contribute to the feelings of helplessness and powerlessness experienced by the nursing aides. A study on nurses in home care showed that they adopted different roles when entering the patient's home and needed courage to overcome the situations they faced (Öresland, Määttä, Norberg, Jorgensen & Lützen, 2008). The courage needed on entering the older persons’ homes can possibly be diminished by the lack of authority. Being courageous and acknowledging their own fear may enrich the professional practice and enable the nursing aides to see beyond their fear and act according to the older persons’ needs and desires. Lindh, da Silva, Berg, and Severinsson (2010) showed that caregivers need courage to see what is, to know what could be and to act as they ought to. The writings of Aristotle suggest that being courageous involves as much fear as the situation requires, as well as the confidence necessary to conquer the fear so as to be able to act (Aristotle, 1967). Aristotle's conception is transferable to the nursing aides who need to be confident enough to acknowledge their fear so that they can act in the best way for the older persons. Holding courage means to understand the professional powers and solid fundaments that embrace and value self, the profession and the patients (Lachman, 2007). In conclusion, caring for older persons with mental disorders involves characteristics in ethical care such as awareness, amenability, knowledge and attentiveness (LaSala & Bjarnason, 2010). Being altruistically egoistic can be understood as involving all the characteristics, including courage as important and all-embracing. The nursing aides may develop from their experiences but, as Barker (2000) suggests, consciousness about the older persons’ lifeworld and caring with the older person are essential elements in the nursing aides’ development of their personal and caring skills. Future studies will include illuminating older persons’ own experiences of their daily life, health and the care they receive.

Methodological considerations

In order to reach a varied sample, the study originally had a purposeful sampling. Nursing aides of both sexes, with different experiences of caring for older persons with non-dementia mental disorders and varying length of experience in the home help service were sought-after. However, the study faced several challenges such as encountering many organizations where persons with mental disorders above the age of 65 were excluded from the services. Thus, several organizations were contacted but only the six included in the study visited older persons with mental disorders. Additionally, at the organizations included in this study, the superiors had chosen one or two of the staff that were assigned to caretakers with mental disorders, and thus only nine nursing aides were eligible for the study. No male nursing aides were assigned to caretakers with mental disorders. All of the reasons above resulted in a convenient sampling where all nursing aides eligible were included. However, the nursing aides’ narratives were considered to offer enough variation and depth to be included in the analysis, since the sample size in life-world research is more dependent on the richness and variation of the narratives, than on exact numbers or saturation (Dahlberg, Dahlberg & Nyström, 2008). The participants were without exception experienced female nursing aides and thus the analyzed text only depicts their perspective. However, the understanding that emerged from the text is relevant for others who care for older persons or persons with mental disorders as well, as it goes further than the narrated experiences of these nine nursing aides. However, the reader need to incorporate the understanding to their own situation for it to improve the care (Lindseth & Norberg, 2004; Dahlberg et al., 2008). As the nursing aides narrated different situations, positive as well as negative, worked in different organizations and visited different older persons the phenomenon has been allowed to vary to the extent possible. With the limitations in sample size and accessibility to more nursing aides the text still includes a fairly large amount of variation and thus the generalizability increases.

The interpretation of the findings presented in this study is one of several (Ricoeur, 1976) and to achieve a deeper understanding of the text we have chosen to interpret and reflect on the findings from the perspective of ethics, utilitarianism and interpersonal nursing theories. Several possible philosophies and theories relevant for widening and deepening the understanding of the text were examined. The philosophies and theories chosen were scrutinized and found to be fruitful for the study, contributed well to a new deeper understanding and were congruent with the aim and the theory of science behind the method and design. However, different understandings may emerge in light of other theories and philosophies. The findings do bring a deeper understanding of the meaning of caring for older persons with mental disorders and must be considered as a part of an ongoing discourse.

The concept of “Mental disorders” is a broad concept which can include several different disorders. However, this was deliberately not explained to the nursing aides as they were encouraged to narrate situations freely where they encountered older persons with non-dementia mental disorders. Thus, it is their individual narratives and their lived experience that has been analysed. The method aims at reaching narrated situations that had affected them to some extent. During the analysis themes emerged that indicate deeper similarities in the nursing aides’ narratives irrespective of the specific disorder of each older person, so the comprehensive concept “Mental disorders” is continuously used in this study.

Even though the authors’ ambitions were to bracket the pre-understanding it is never completely feasible, as it constitutes our basis in life and as nothing is understandable except in the light of the pre-understanding. However, with awareness about different aspects of the pre-understanding, preconceived ideas and judgements are bracketed to allow the implicit meaning appear. Matters otherwise taken for granted have been enlightened and discussed together in the light of the authors’ different experiences. During the analysis the findings were thoroughly scrutinized and discussed until consensus was reached. The first author has been responsible for data collection, analysis and preparation of the manuscript. However, trustworthiness was ensured as all four authors have been implicated in the whole research process and contributed different aspects depending on previous experiences and knowledge.

Implications

To maintain courage and the possibility of caring for older persons with mental disorders in their own homes it seems important to alter the approach to the old, where necessary. A previous study has shown that in order for older persons to experience the care they receive as good, they need to be acknowledged as fellow human beings (From, Johansson & Athlin, 2009), even in ethically difficult situations. This implies making an effort to dare opening up for the older persons’ lifeworld and acknowledging the differences. Without openness for the different, egoistic actions may prevail over the altruistic, thus resulting in imbalance. Even though the nursing aides are trying to embrace the whole person, lack of knowledge may spoil their effort. They require skills to deal with their own feelings of fear, insecurity and failing. Clinical supervision has been found relevant for personal development (Häggström et al., 2010) and necessary when facing ethical dilemmas (Nordam, Torjuul & Sorlie, 2005) and may be relevant as a tool for the nursing aides. To profit from the suggested supervision it should be based on an increased knowledge of how to deal with the issues in question. This knowledge may be provided in the organizations through training sessions that raise the level of awareness about diversity among older persons, and tackle questions such as how to achieve openness and to gain the courage needed to be present and participate in the conversation with the old without it resulting in compassion fatigue. In order for new knowledge to be implemented in the nursing aides’ work situation, it should be discussed and reflected upon in connection with practical situations and during supervision. As the insecurity experienced by nursing aides might be reflected in the older persons’ actions and behaviour, continuous training and supervision might offer them more security and redress the balance between altruism and egoism. This may also generate a feeling of security for the older persons, thus benefitting all. Consequently this will improve the care given.