The qualitative portfolio at The Gerontologist: strong and getting stronger

Beyond error: A qualitative study of human factors in serious adverse events

The field of healthcare quality and safety has been informed by the study of Human Factors contributing to adverse events. Hitherto, much of the study of Human Factors has been focused on a narrow lens of human error, identifying cognitive-based or knowledge-based errors and cognitive processes such as loss of situational awareness contributing to error. While these factors are important, this narrow approach fails to consider the complexity of relational and systemic factors that also contribute to adverse events. We aimed to explore the relational and systemic human factors, including shared clinician attitudes and behavior, that contribute to serious adverse patient events in a public health setting. The study, set in a metropolitan local health district in New South Wales, Australia, was conducted using a retrospective qualitative multi-incident content analysis design. Serious adverse event reviews (SAER) over 6 months (2022-2023) were subject to qualitative content analysis until data saturation was reached. Data saturation reached at 20 reports. Emergent themes related to human factors in serious adverse events included: (i) delays and inertia-with a subtheme of inertia of ageism; (ii) "All-or-nothing" approach to end-of-life care and planning; (iii) communication lapses; and (iv) implementation gap between standards and practice. Error-based incidents accounted for only 35% of the serious adverse events examined. The sample studied involved mostly (65%) male patients, with a mean age of 69 (70% aged >65), managed across the gamut of specialties, with the most common incident being the management of acutely deteriorating patients. In conclusion, there is more to Human Factors in adverse events than cognitive or knowledge-based error. While identifying and correcting errors is absolutely essential, we need adjunctive "soft measures" to address clinical attitudes, behaviors, and relationships in health care, particularly in increasingly complex, fraught, and stressful health care environments.

Family Caregivers as Employers of Migrant Live-In Care Workers: Experiences and Policy Implications

As policymakers globally recognize aging in place as the preferred option for most adults, there is a growing need to supplement family or informal caregiving for frail older adults with formal homecare services, particularly for those who require 24/7 care due to significant physical and/or cognitive impairment. The core objective of this qualitative study was to explore family members' experiences in employing live-in care workers, particularly the nature of their engagement and the quality of their relationships with these care workers. Our analysis of semi-structured interviews with 35 family caregivers revealed four themes: 1) challenges in acquiring support and developing dependency; 2) negotiation of roles, responsibilities, and moral dilemmas; 3) shifting emotions between trust and suspicion; and 4) role confusion, expectations, and disappointments. The study suggests that families might benefit from formal guidance regarding fostering and maintaining positive relationships in the homecare environment. This paper provides nuanced knowledge that may inform the development of such interventions.

Use of Long-Term Care Services by Older Persons with Limited English Proficiency

Older migrants face special difficulties in the access and use of long-term care services and supports (LTSS). Our study was designed to examine how older persons with limited English proficiency (LEP) in two groups of migrants (Spanish or Chinese speaking) interact with the LTSS system. Focus groups were used to elicit information from members of these groups. We discovered Chinese elders were likely to believe that the LTSS services could, if managed properly, meet their needs, while the Spanish speakers were more skeptical. These differences were associated with the presence of trusted intermediaries among the Chinese elders who could represent their interests, while most Spanish speakers did not report having such intermediaries. In this way, trust, or lack of it, was uncovered as the key element defining older adults' interactions with the formal health and social service systems. Findings will be used to develop a modeling method that will allow us to analyze results in a manner that can be extended to use with other migrant groups.

The qualitative embedded case study method: Exploring and refining gerontological concepts via qualitative research with older people

This article argues that a tailored version of the qualitative embedded case study method can be used to build strong conceptual and inclusive insights from qualitative research with older people, and, in doing so, advance theoretical scholarship in social and critical gerontology. Gerontology has often been described as "data-rich and theory-poor" (Birren & Bengtson, 1988). It is a field which draws heavily on post-positivist traditions of quantitative research and notions of prediction, generalization, and statistical significance. While critical qualitative approaches have gained ground through interdisciplinary scholarship in the social sciences and humanities, few attempts have been made to articulate the relationship between research questions designed to understand older people's experiences and concept- or theory-building in gerontology. This piece makes a case for engaging with the theoretical/methodological interface by drawing on an evolving approach entitled the qualitative embedded case study, as it was used in three qualitative studies on the concepts of frailty, (im)mobility, and precarity. It suggests this is an evolving approach with the potential to develop conceptually sound, meaningful research from older people's experiences, including diverse, underrepresented, and marginalized groups, and to draw on these insights to direct change.

Health care network model for older adults: a co-creation and participatory action research approach

Objective: To develop a collaborative, multidisciplinary care model for older adults that improves interdisciplinary teamwork and increases access to specialized services for frail patients, helping solve management problems in the Brazilian Unified Health System. In the state of Bahia, the health care network for older adults requires better interaction and integration with the Unified Health System and the Unified System of Social Assistance to improve patient flow in the network. Methods: We used a co-creation and participatory action research approach based on reflection, data collection, interaction, and feedback with participants and stakeholders. Data was collected from health professionals, representatives of health agencies, and older adults through collective and individual interviews, reflective diaries, and direct communication. Results: An action plan involving members of the older adult care network was developed to put the new model into practice. A pilot study with a multidisciplinary team allowed adjustments and implementation of the model at our institution. Conclusions: The new model improved both the internal management of the State Reference Center for Older Adult Health Care (Centro de Referência Estadual de Atenção à Saúde do Idoso - CREASI) and its interaction with primary care, optimizing patient flow and establishing rules for shared management between CREASI and primary care institutions. In view of this, restructuring the care model reorganized relations between the agencies, expanding CREASI’s role in the management and systematization of older adult health.

Facilitating Age-Conscious Student Development through Lecture-Based Courses on Aging

Ageism is pervasive and socially normalized, and population aging has created a need to understand how views of aging and of older people, typically considered to be people over the age of 65, can be improved. This study sought to understand how undergraduate students’ attitudes towards older adults and the aging process may be influenced after completing a typical, lecture-based undergraduate course on aging that lacked service-learning components. Two undergraduate student cohorts (n = 40) at two Canadian universities participated in semi-structured focus groups/interviews, describing how the course may have impacted their perceptions of the aging process and of older adults. An iterative collaborative qualitative analysis demonstrated that course content stimulated a deeper understanding of the aging process, prompting a reduction in and increased awareness of ageism, and enhanced personal connection with aging, ultimately facilitating the development of an age-conscious student. Lecture-based courses focused on aging may be sufficient to facilitate positive attitude change among undergraduate students towards older adults and the aging process.

"We Never Graduate from Care Giving Roles"; Cultural Schemas for Intergenerational Care Role Among Older Adults in Tanzania

This paper examines the cultural schemas underlying older persons' perception of intergenerational care roles. Thirty qualitative in-depth interviews and twenty focus group discussions (N = 120) were conducted among older women and men aged 60 and above. By using this theory, we were able to identify a series of cultural schemas found in older people's discussions of intergenerational caregiving role. The most prominent shared schemas are; caregiving for elderly is a cultural obligation not a choice, caregiving is a sign of respect, caregiving is a sign of love, caregiving is a source of pride, and caregiving leads to attachment and emotional bonds. Based on these schemas, older people perceived getting care from one's children as a cultural obligation and not an individual (child) choice. However, the findings show that older people's life experience differed greatly from the cultural schemas they had as majority were not cared for by their children. Thus, the discrepancies between schemas/expectations and realities of older people led to tension, sadness, frustration and feeling of being neglected. This study suggests that there is need to put in place interventions that encourage intergenerational caregiving. These intervention programmes should seek not only to consider but also to build upon the strength of cultural values and beliefs.

Expectations and Concerns of Older Adults With Cognitive Impairment About Their Relationship With Medical Providers: A Call for Therapeutic Alliances

We sought to understand the expectations and concerns of older adults with cognitive impairment with regard to their relationship with medical providers. In particular, we observed whether study participants were involved in therapeutic alliances. Medical providers and patients create therapeutic alliances when they agree on the goals of the treatment and share a personal bond. Whereas such alliances have been studied in cancer research, little is known about therapeutic alliances in dementia research. Data were gathered in a qualitative study of 27 older adults with cognitive impairment and analyzed with narrative analysis. We introduce four case studies that illustrate the effects of having or missing a therapeutic alliance. Whereas the participant in the first case benefited from a therapeutic alliance, the other cases are marked by different experiences of abandonment. Findings suggest that interventions should concentrate on ways to enhance the relationship between medical providers and patients with cognitive impairment.

A Qualitative Evidence Synthesis Review of Longitudinal Qualitative Research in Gerontology

BACKGROUND AND OBJECTIVES

Gerontologists have long been interested in longitudinal qualitative research (LQR), yet ambiguity remains about best practices. The purpose of this review was to conduct a qualitative evidence synthesis to identify strengths and limitations in existing gerontological LQR.

RESEARCH DESIGN AND METHODS

We searched for studies published in English before September 2017, using longitudinal qualitative methods and focusing on gerontology. We searched the following databases: PubMed and ProQuest. This was followed up by a snowball search to identify additional LQR articles that were not gerontologically focused but provided conceptual or methodological information to enhance gerontological LQR. Article titles and abstracts were reviewed, and selected articles were independently evaluated by all authors and summarized in a descriptive matrix based on design, analysis, and strengths and limitations.

RESULTS

Our literature search resulted in 225 articles, which was then narrowed to 71 articles from 47 different journals based on our inclusion/exclusion criteria. LQR in gerontology varies considerably by study design and analysis approach. LQR design considerations involve number of time points and duration; rapport and retention; and consistent or different sampling, data collection, and measures. LQR analysis considerations involve synchronic and diachronic approaches, consistent or evolving coding, and individual- or group-level analysis. Gerontological LQR articles vary in the extent to which they address special aging considerations.

DISCUSSION AND IMPLICATIONS

This review indicates that there are areas where gerontological LQR can be strengthened going forward. We provide researchers with strategies to improve LQR rigor in our field and beyond.

"I Have to Listen to This Old Body": Femininity and the Aging Body

BACKGROUND AND OBJECTIVES

This study explores how older women with low socioeconomic status living in rural Tanzania give meaning to their (aging) body in relation to the ideals of femininity.

RESEARCH DESIGN AND METHODS

Ten qualitative in-depth interviews and 10 focus group discussions (N = 60) were conducted among women aged 60 and older.

RESULTS

The findings reveal that older women perceive their aging body as "a burden." This characterization of the body is linked to the inability of the aging body to live up to the women's gendered lives. The conflict between their physical limitations and the desire to perform gendered tasks (internalized feminine habitus) affect the women's process of self-identification. This led to emotional distress and subsequently threatened their survival and well-being.

DISCUSSION AND IMPLICATIONS

The results suggest that older women need to be supported through interventions that are tailored to their cultural and socioeconomic context.

The Precarity of Older Adults Living Alone With Cognitive Impairment

PURPOSE OF THE STUDY

To examine the lived experience of older adults living alone with cognitive impairment to better understand their needs and concerns. Based on our previous work suggesting that older adults living alone often experience a sense of precarity, we were interested in exploring this construct in older adults living alone with a diagnosis of cognitive impairment. The notion of precarity points to the uncertainty deriving from coping with cumulative pressures while trying to preserve a sense of independence.

DESIGN AND METHODS

This is a qualitative study of 12 adults aged 65 and older living alone with cognitive impairment. Six participants had a diagnosis of Alzheimer's disease; 6 had a diagnosis of mild cognitive impairment. Participants' lived experiences were elicited through 40 ethnographic interviews and participant observation in their homes. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes.

RESULTS

Qualitative analysis of transcripts revealed three themes. Theme 1 described the distress stemming from the uncertainty of having cognitive impairment that has an unpredictable course. Theme 2 drew attention to the tendency of participants to feel responsible for managing their cognitive impairment. Theme 3 described the pressures stemming from the lack of appropriate services to support independent living for persons with cognitive impairment.

IMPLICATIONS

These 3 themes all pointed to facets of precarity. Findings also suggest the dearth of programs to support older adults living alone with cognitive impairment and the need to develop novel programs and interventions.

The Effects and Meanings of Receiving a Diagnosis of Mild Cognitive Impairment or Alzheimer's Disease When One Lives Alone

BACKGROUND

One third of older adults with cognitive impairment live alone and are at high risk for poor health outcomes. Little is known about how older adults who live alone experience the process of receiving a diagnosis of mild cognitive impairment (MCI) or Alzheimer's disease (AD).

OBJECTIVE

The aim of this study was to understand the effects and meanings of receiving a diagnosis of MCI or AD on the lived experience of older adults living alone.

METHODS

This is a qualitative study of adults age 65 and over living alone with cognitive impairment. Participants' lived experiences were elicited through ethnographic interviews and participant observation in their homes. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes.

RESULTS

Twenty-nine older adults and 6 members of their social circles completed 114 ethnographic interviews. Core themes included: relief, distress, ambiguous recollections, and not knowing what to do. Participants sometimes felt uplifted and relieved by the diagnostic process. Some participants did not mention having received a diagnosis or had only partial recollections about it. Participants reported that, as time passed, they did not know what to do with regard to the treatment of their condition. Sometimes they also did not know how to prepare for a likely worsening of their condition, which they would experience while living alone.

CONCLUSION

Findings suggest the need for more tailored care and follow-up as soon as MCI or AD is diagnosed in persons living alone.

Medical student reflections on geriatrics: Moral distress, empathy, ethics and end of life

Medical students' early clinical encounters may influence their perceptions of geriatrics. This study examines reflective essays written by 3^rd-year medical students on required clinical rotations. Using content analysis, the authors analyzed the essays' thematic content. The authors then used chi-squared analysis to compare themes with geriatric patients (age 60+) to themes with other age groups. One hundred twenty out of 802 essays described a geriatric patient. The most common geriatric themes were (1) death and dying, (2) decision making, (3) meaningful physician-patient interactions, (4) quality of care, and (5) professional development. Geriatric essays were more likely to discuss death/dying and risk-benefit themes and less likely to discuss abuse. Geriatric essays were more likely to describe students' moral distress. Geriatric essays with moral distress were more likely to include empathy themes compared to geriatric essays without moral distress. Geriatric patients may pose unique ethical challenges for early clinical students.

Qualitative Research in the CJA/RCV: An 18-Year Analysis (1995-2012)

Some researchers have suggested that qualitative research is increasing in the gerontology field, but little systematic analysis has tested this assertion. Using the Canadian Journal on Aging/La Revue canadienne du vieillissement as a case study, we analysed articles reporting on original research from 1995 to 2012. One in four articles were qualitative, and results in three-year intervals show a clear increase in qualitative research findings during this 18-year time frame: (a) 1995-1997: 10 per cent; (b) 1998-2000: 19 per cent; (c) 2001-2003: 25 per cent; (d) 2004-2006: 25 per cent; (e) 2007-2009: 29 per cent; and (f) 2010-2012: 43 per cent. In all time intervals (with the exception of 2004-2006), French language articles were more likely to use a qualitative research design compared to English language articles. Topics, methodologies, and data collection strategies are also discussed.

The Significance of Sexuality and Intimacy in the Lives of Older African Americans With HIV/AIDS

PURPOSE OF THE STUDY

Aging and HIV/AIDS research focuses primarily on standardized clinical, social, and behavioral measures, leaving unanswered questions about how this chronic and stigmatizing condition affects life course expectations and the meaning of aging with the disease. Utilizing Gaylene Becker's (1997) life course disruption theory, we explored older African Americans' experiences of living with HIV/AIDS.

DESIGN AND METHODS

A purposive sample (N = 43) of seropositive African Americans aged 50 and older was selected from a parent study. Thirteen participants completed one semi-structured in-depth interview on life course expectations and experiences of living with HIV/AIDS. Interview transcripts were analyzed using standard qualitative coding and thematic analysis.

RESULTS

Responding to broad, open-ended questions about the impact of HIV on life course expectations, participants emphasized how HIV limited their ability to experience sexuality and intimacy. Two major themes emerged, damaged sexuality and constrained intimacy.

IMPLICATIONS

Older African Americans' discussions of living with HIV focused on the importance of and the challenges to sexuality and intimacy. Researchers and clinicians should be attentive to significant and ongoing HIV-related challenges to sexuality and intimacy facing older African Americans living with HIV/AIDS.

Physical and Psychosocial Function in Residential Aged-Care Elders: Effect of Nintendo Wii Sports Games

This mixed-methods, quasi-experimental pilot study examined whether the Nintendo Wii Sports (NWS) active video game (exergame) system could significantly improve the functional ability, physical activity levels, and quality of life of 34 older adults (4 men and 30 women, 83 ± 8 yr) living in 2 residential aged-care (RAC) centers. Change score analyses indicated the intervention group had significantly greater increases in bicep curl muscular endurance, physical activity levels, and psychological quality of life than the control group (p< .05). Analysis of the quotes underlying the 3 themes (feeling silly, feeling good; having fun; and something to look forward to) suggested that intervention group participants developed a sense of empowerment and achievement after some initial reluctance and anxiousness. They felt that the games were fun and provided an avenue for greater socialization. These results add some further support to the utilization of NWS exergames in the RAC context.

Gaps, disconnections, and discontinuities--the role of information exchange in the delivery of quality long-term care

PURPOSE OF THE STUDY

The smart use of information and communication technologies (ICT) is widely seen as a means of enhancing the quality of aged care services. One of the barriers to ICT diffusion in aged care is the failure to cater for the complex and interdisciplinary requirements of the aged care environment. The aim of this qualitative study was to identify the layers of information exchange and communication and produce a conceptual model that can help to inform decisions related to the design, implementation, and sustainability of ICT.

DESIGN AND METHODS

A qualitative study conducted in 2010 within seven Australian residential aged care facilities. It included 11 focus groups involving 47 staff and 54 individual interviews and observation sessions.

RESULTS

The analysis of work processes identified key information exchange components related to the type of information (residential, clinical, and administrative) that is collected, stored, and communicated. This information relies on a diverse number of internal and external communication channels that are important for the organization of care.

IMPLICATIONS

The findings highlight potential areas of communication dysfunction as a consequence of structural holes, fragmentation, or disconnections that can adversely affect the continuity and coordination of care, its safety, and quality.

Grandparents of Grandchildren with Autism Spectrum Disorders (ASD): Strengthening Relationships through Technology Activities

This study of grandparent-grandchild relationships was embedded in the context of technology workshops offered for young children on the autism spectrum. The purpose of this research was to examine the perspectives of six involved grandparents regarding their social interactions with their grandchildren in the context of this shared technology experience. Content analysis of transcribed focus group sessions with the grandparents indicated two key themes: expectations were reframed and communication bridges were built through shared interests. Grandparents perceived that their grandchildren learned technological skills, and increased their social interactions with peers, family members (parents, siblings), and grandparents themselves. The positive experience the grandparents perceived their grandchildren to have in the program gave them hope for future educational and employment opportunities for their grandchildren. The grandparents also indicated that the shared interests in the computer program facilitated communication opportunities with their grandchildren, with other grandparents of grandchildren with ASD, and with their adult sons and daughters.