Afraid to care; unable to care: A critical ethnography within a long-term care home

“Acting ethically is down to you” applying ethical protocols in qualitative fieldwork in care homes

Purpose

Research ethics committees (RECs) and ethical standards govern research. To conduct research involving participants, researchers must first gain a favourable opinion on their protocol from a REC. This paper aims to promote researcher reflexivity and openness about applying agreed ethical protocols in practice.

Design/methodology/approach

Using examples from qualitative fieldwork in two care home studies, the authors critically reflect on the issues encountered when applying ethics committee agreed protocols in real-world situations.

Findings

Three areas of research practice are reflected on given as follows: recruitment and consent; approach to observations; and research processes, shared spaces and access to data. The interface between researcher and participant did not always mirror textbook scenarios. Ultimately, this left researchers accountable for taking ethically acceptable actions while conducting research.

Originality/value

Drawing on research experiences in care homes, the authors consider the reliance on the researcher to be authentic and morally driven over and above formal ethical approvals. The authors conclude that the researcher is the bridging agent between ethical protocols and ethical practice in the field. As such, researchers need to be open and reflexive about their practices in fieldwork.

Vital correspondence: Exploring tactile experience with resident-focused mandalas in long-term care (Innovative practice)

The materiality of long-term care and its relationship to a resident’s identity is often overlooked. In response to the call for more attention to the meaningful aspects of doing art, the tactile experience of residents with dementia is considered in the context of a mandala project at a Canadian seniors’ long-term care facility. The significance of making mandalas for residents is explored through three key themes: identity integration through gesture, the importance of artistic discernment and decision-making, and the value of corresponding with recalcitrant materials. Residents’ experiences are analysed through a phenomenological lens.

Structures, tensions, and processes shaping long-term care home staff's role in end of life decision-making for residents with dementia

Although long-term care (LTC) home staff of nurses and personal support workers spend the most time providing direct care, their role in end of life decision-making for residents with dementia has largely been unacknowledged. Staff's perceptions of their role play a significant part in how they support people with dementia and family care partners. The purpose of this study was to examine LTC home staff's perspectives of their role in end of life decision-making for LTC home residents with dementia. For this interpretive descriptive study, 21 semi-structured interviews were conducted in two urban LTC homes with nine personal support worker (PSWs), eight registered practical nurses (RPNs), and four registered nurses (RNs). Additionally, a focus group was conducted, consisting of each a PSW, RPN, and RN. A voice-centred relational analysis was used to situate LTC home staff's perspectives within broader social contexts. Findings suggest that little has changed in LTC homes in the last 50 years. Rooted in dichotomies between medical and social care paradigms, ideologies of rationality and professionalism created tensions, hierarchical roles, and staff's minimal involvement in decision-making. A relational approach is needed to account for the interdependency of care and the relationships that LTC home staff have with residents, family care partners, and the sociopolitical environment.

Supporting staff as change leaders in consumer engagement in aged care: Learnings from action research

AIM

The aim of this paper is to explore the process of staff leading change in consumer engagement practice in aged care.

BACKGROUND

Shifting expectations make engagement practice increasingly complex for service providers. This requires adaptive change within organisations. Organisations need to empower and support staff to critically assess practice, identify issues and pursue opportunities for innovation.

METHOD

Data were collected as part of an action research project addressing client engagement practice in Australian aged care. Staff worked together to identify issues for practice, generate solutions and create change within their organisations.

RESULTS

Staff identified innovative ways of generating change, demonstrating leadership. However, a range of technical, practical, systemic and philosophical factors impacted their progress.

CONCLUSIONS

Staff are effective, proactive change agents who can provide valuable insights into directions for their organisations and can lead practice improvement in engagement. However, they require support through the organisational environment.

IMPLICATIONS FOR NURSING MANAGEMENT

Staff in all roles can demonstrate adaptive leadership in changing engagement practice. However, those in traditional roles of authority need to recognize their own roles in showing leadership and supporting adaptive change. This provides a new insight into how managers can support practice change in consumer engagement.

Health States of Exception: unsafe non-care and the (inadvertent) production of 'bare life' in complex care transitions

This paper draws on the work of Giorgio Agamben to understand how the social organisation of care transitions can reduce people to their 'bare' life thereby making harmful and degrading treatment seemingly legitimate. The findings of a 2-year ethnographic study show how some people experience hospital discharge as undignified, inhumane and unsafe process, expressed through their lack of involvement in care planning, delayed discharge from hospital and poorly coordinated care. Our analysis explores how these experiences stem from the way patients are constituted as 'unknown' and 'ineligible' subjects and, in turn, how professionals become 'not responsible' for their care. The result being that the person is reduced to their 'bare' life with limited value within the care system. We suggest that the social production of 'bare life' is an inadvertent consequence of reconciling and aligning multiple disciplines within a complex care system.

The "Violent Resident": A Critical Exploration of the Ethics of Resident-to-Resident Aggression

Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the "violent resident." It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.

The Influence of the Physical Environment on Residents With Dementia in Long-Term Care Settings: A Review of the Empirical Literature

Background and Objectives

The physical environment in long-term care facilities has an important role in the care of residents with dementia. This paper presents a literature review focusing on recent empirical research in this area and situates the research with therapeutic goals related to the physical environment.

Research Design and Methods

A comprehensive literature search was conducted in Ageline, PsychINFO, CINAHL, Medline and Google Scholar databases to identify relevant articles. A narrative approach was used to review the literature.

Results

A total of 103 full-text items were reviewed, including 94 empirical studies and 9 reviews. There is substantial evidence on the influence of unit size, spatial layout, homelike character, sensory stimulation, and environmental characteristics of social spaces on residents' behaviors and well-being in care facilities. However, research in this area is primarily cross-sectional and based on relatively small and homogenous samples.

Discussion and Implications

Given the increasing body of empirical evidence, greater recognition is warranted for creating physical environments appropriate and responsive to residents' cognitive abilities and functioning. Future research needs to place greater emphasis on environmental intervention-based studies, diverse sample populations, inclusion of residents in different stages and with multiple types of dementia, and on longitudinal study design.

The Distribution of Regulation in Aged and Dementia Care: A Continuum Approach

The regulation of care services has become the principal means by which the state influences provision. In this article we examine the regulation of dementia care within organizations to show how some care activities attract more regulation than others. While often perceived to be overwhelming, regulation is in fact unevenly distributed at the system, organization and, in particular, the care practice levels. In practice, some areas of care are heavily regulated, while others are less so. Drawing on research interviews with staff (N = 60) at three levels of care provider organizations-senior managers, facility managers, and direct care workers-a continuum of regulation, with regulations collecting around some care activities and not others, is developed. This is used to plot how different care activities are affected by regulation. Understanding how regulations collect around some activities and not others shows where flexibility and innovation in care are possible. This has implications for the discretion care workers can exercise in daily care, effective organizational strategies for managing care and regulation, and regulatory policy. Current debates around regulation should shift from notions of good/bad and more/less regulation to an analysis of how regulation creates areas that are closely controlled and those that allow practice innovation.

Introduction to positivism, interpretivism and critical theory

BACKGROUND

There are three commonly known philosophical research paradigms used to guide research methods and analysis: positivism, interpretivism and critical theory. Being able to justify the decision to adopt or reject a philosophy should be part of the basis of research. It is therefore important to understand these paradigms, their origins and principles, and to decide which is appropriate for a study and inform its design, methodology and analysis.

AIM

To help those new to research philosophy by explaining positivism, interpretivism and critical theory.

DISCUSSION

Positivism resulted from foundationalism and empiricism; positivists value objectivity and proving or disproving hypotheses. Interpretivism is in direct opposition to positivism; it originated from principles developed by Kant and values subjectivity. Critical theory originated in the Frankfurt School and considers the wider oppressive nature of politics or societal influences, and often includes feminist research.

CONCLUSION

This paper introduces the historical context of three well-referenced research philosophies and explains the common principles and values of each.

IMPLICATIONS FOR PRACTICE

The paper enables nurse researchers to make informed and rational decisions when embarking on research.

Staff personhood in dementia care settings: "Do they care about me?"

AIMS AND OBJECTIVES

This article aims to examine RCAs' own experiences of personhood in dementia care settings.

BACKGROUND

Conceptually, person-centred care entails fostering the personhood of residents and the residential care aides (RCAs) who provide much of their hands-on care. To date, however, staff personhood has been overlooked in the empirical literature.

DESIGN

The study was part of a larger focused ethnographic project exploring how the organisational care environment impedes or facilitates the provision of quality dementia care.

METHODS

Semi-structured interviews with 23 RCAs and more than 230 hours of participant observation were conducted in two nursing homes with specialised dementia units in British Columbia, Canada.

RESULTS

Two overarching themes, "personhood undermined-management-staff relations" and "personhood undermined-workplace policies and practices" emerged, illustrating how, despite exposure to features believed beneficial to their working environment (e.g., favourable staffing ratios, relatively good remuneration), RCAs encountered repeated affronts to their personhood. The first theme encompasses the importance of being known (i.e., as persons and of their job demands) and valued (i.e., appreciated for their work in non-monetary terms). The second highlights the salience of work-life balance, full-staffing coverage and supportive human resource practices.

CONCLUSIONS

RCAs' experiences reveal how the ongoing search for cost-efficiencies, cost-containment and cost-accountability overshadows their individuality, indicating a key disconnect between conceptual ideals and workplace realities.

IMPLICATIONS FOR PRACTICE

Organisations are encouraged to consider creating person-centred management and workplace practices that provide tangible evidence that RCAs, and their work, matter.

What does client ‘engagement’ mean in aged care? An analysis of practice

Client engagement is an important part of contemporary aged care. However, the extent to which decisions are delegated to the older person, and the scope of issues about which decision making occurs, vary. The types of engagement that are offered to, and taken up by, aged-care clients have implications for the extent of power and influence older people hold. This paper reports on a qualitative study conducted in a large Australian service provider. It identifies the forms that client engagement takes in the aged-care context, the roles for staff and older people that are enacted through these activities, and the implications these have for power relationships and older people's influence. An inverse relationship was seen between the depth and scope of client influence, but a desire to address this suggested potential spaces for greater empowerment. A relationship was evident between the retention of control by staff and the perceived effectiveness of existing engagement strategies, highlighting the limitations of traditional power dynamics in engagement practice. An expanded model of engagement in aged care is proposed that recognises the foundational role of connection building as a facilitator of greater empowerment for older people. Implications for theory regarding engagement in aged care, and the practice of engagement in aged-care organisations, are discussed.

Whose responsibility is it to make life worth living?

In this editorial, we hope to reflect the image of current care, often labeled as good care, in nursing homes. The data are anecdotal, based on our visits to several clinical team meetings in nursing homes, but they raise issues which are common and need to receive higher priority.

Theoretical foundations guiding culture change: The work of the Partnerships in Dementia Care Alliance

Longstanding concerns about quality care provision, specifically in the area of long-term care, have prompted calls for changing the culture of care to reflect more client-driven and relationship-centred models. Despite an increase in culture change initiatives in both Canada and the United States, there is insufficient information about the theories and approaches that guide culture change. The purpose of this paper is to describe a culture change initiative currently underway in Canada, the Partnerships in Dementia Care Alliance, and the theoretical foundations informing our work. More specifically, we describe how the theoretical and philosophical underpinnings of the Alzheimer Disease and Related Dementias framework, the authentic partnership approach, participatory action research and Appreciative Inquiry have been integrated to guide a culture change process that encourages working collaboratively, thinking and doing differently and re-imagining new possibilities for changing the culture of dementia care.

Pioneering partnerships: Resident involvement from multiple perspectives

Resident involvement in residential care homes is a challenge due to shortcomings of consumerist and formal approaches such as resident councils. The PARTNER approach aims to involve residents through collective action to improve their community life and wellbeing. The purpose of this article is to provide insights into the process of resident involvement by the PARTNER approach from the perspectives of multiple stakeholders, including residents, volunteers and staff members. A responsive evaluation was conducted, using participant observations, semi-structured interviews with residents, volunteers and professionals (n=16), and three focus groups. The findings show that critical elements in this process of resident involvement were the agenda-setting by residents, the formation of a cohesive resident group, the sharing of experiences and stories, the development of collective action, and the development of partnerships between residents and professionals and other stakeholder groups. Residents developed actions (gallery parties and a buddy project) to strengthen social interactions and realized these with the help of volunteers and professionals. We conclude that bringing residents together around a shared topic creates room for activism and leads to empowerment, feelings of social belonging and learning processes. We argue that it is a worthwhile enterprise to further develop structural partnership relations between residents, volunteers and staff in residential care homes.