Transitions in care homes: towards relationship‐centred care using the ‘Senses Framework’

The use of home care as relational work: outlines for a research programme

PURPOSE

Care has been theorized as a relational practice, but the research has focused on providers rather than users. Older care users have been cast in a passive role, and their relational activities to help with the provision of their care or to support those who provide it are underexplored. The purpose of this study is to develop knowledge about home care use as a form of relational 'work'.

METHODS

The data for the study consists of 34 qualitative interviews with home care users in Sweden and 15 observations of care provision. The data has been coded using thematic analysis.

RESULTS

The analysis identifies two overlapping forms of relational work done by care users in the home care context: care-centred work, where care users work to facilitate care situations that were positive for staff and for the provision of care; and person-centred work, where care users work to foster personal relations by focusing on care staff as unique individuals.

CONCLUSIONS

The article proposes a research programme on relational work by care users, prompted by the finding that such efforts seem central for the understanding of eldercare in a variety of contexts.

Different views on collaboration between older persons, informal caregivers and care professionals

BACKGROUND

Informal care features high on the policy agenda of many countries to deal with workforce shortages. As a consequence, care provision increasingly takes place in the care triad of care recipients, informal caregivers and care professionals. How collaboration between care partners takes shape depends on how the different partners perceive this collaboration. This paper aims to investigate the relative importance of the different aspects of collaboration from the perspectives of care recipients, informal caregivers and care professionals in the context of the care for older persons in The Netherlands.

METHODS

Using Q-methodology, 32 participants ranked 28 statements that reflect different aspects of collaboration in the care triad and explained their ranking during a follow-up interview. Participants comprised 9 older persons, 10 informal caregivers and 13 care professionals. Data were analysed using by-person factor analysis to identify common patterns in the rankings of the statements. Emerging patterns were interpreted and described as views on collaboration using aggregated rankings and qualitative data from the interviews.

RESULTS

Five distinct views on collaboration were found: (1) Emphasizing warm collaboration, (2) trusting care professional's expertise, (3) open and compassionate care professionals, (4) responsive decision-making by autonomous care professionals and (5) prioritizing care recipient's and informal caregiver's interests. Care recipients and/or informal caregivers were associated with views 1, 3 and, 5, whereas care professionals were associated with all five views.

CONCLUSIONS

Our study highlights the importance of recognizing the potential diversity of views between and within different partner groups in care triads. Governmental and organizational policy makers, as well as healthcare professionals who aim to increase or support the involvement of informal caregivers, should take this heterogeneity into consideration.

PATIENT OR PUBLIC CONTRIBUTION

An advisory board of older persons (care recipients and informal caregivers) was involved in the recruitment of the participants, the formulation of the statements and the reflection on the findings of the study and potential implications.

Quality in care homes: How wearable devices and social network analysis might help

Social network analysis can support quality improvement in care homes but traditional approaches to social network analysis are not always feasible in care homes. Recalling contacts and movements in a home is difficult for residents and staff and documentary and other sources of individual contacts can be unreliable. Bluetooth enabled wearable devices are a potential means of generating reliable, trustworthy, social network data in care home communities. In this paper, we explore the empirical, theoretical and real-world potential and difficulties in using Bluetooth enabled wearables with residents and staff in care homes for quality improvement. We demonstrate, for the first time, that a relatively simple system built around the Internet of Things, Bluetooth enabled wearables for residents and staff and passive location devices (the CONTACT intervention) can capture social networks and data in homes, enabling social network analysis, measures, statistics and visualisations. Unexpected variations in social network measures and patterns are surfaced, alongside "uncomfortable" information concerning staff time spent with residents. We show how technology might also help identify those most in need of social contact in a home. The possibilities of technology-enabled social network analysis must be balanced against the implementation-related challenges associated with introducing innovations in complex social systems such as care homes. Behavioural challenges notwithstanding, we argue that armed with social network information, care home staff could better tailor, plan and evaluate the effects of quality improvement with the sub-communities that make up a care home community.

Exploring nursing home resident and their care partner priorities for care using the Action-Project Method

BACKGROUND

Nursing home (NH) residents' experiences are embedded within their relationships to others. Our objectives were to describe how residents and care partners (family or staff members) jointly construct, discuss, and act on care priorities.

METHODS

We used Action-Project Method, a qualitative method focused on action within social context. We recruited 15 residents and 12 care partners (5 family and 7 staff members) from 3 urban NHs in Alberta, Canada. Residents and care partners participated in a video-recorded conversation about their experiences in the NH, then individually reviewed the video-recording to add context to the conversation. Following transcription, preliminary narrative construction, and participant feedback, the research team conducted in-depth analysis to identify participant actions, goals, and projects, including those jointly shared by dyad members.

RESULTS

All participants' intentions could be broadly described as "making time in the NH as good as possible" and projects were grouped into five categories: resident identity, relationships (both presence and absence), advocacy, positivity, and respectful care. Participants often raised issues of short-staffing as a significant barrier to respectful care. Care partners, especially staff, used positivity to redirect residents from difficult topics. Joint projects could be identified in some, but not all, cases.

CONCLUSIONS

We found that maintaining a sense of identity, fostering relationships, and receiving respectful care were important to residents but that short-staffing created barriers. Methods to capture these aspects of the resident experience are needed but should not be influenced by care partners' tendency towards positivity in resident interactions.

Our dementia challenge: arise palliative care

While many of the maladies of the 20th century are steadily coming under control, the march of neurodegenerative disorders continues largely unchecked. Dementias are an exemplar of such disorders; their incidence and prevalence continue to rise, in large part due to a steadily ageing population worldwide. They represent a group of chronic, progressive and, ultimately, fatal neurodegenerative diseases. Dementia has remained therapeutically recalcitrant. It is not a single disease, and because of that, we cannot expect a single panacea. While primary prevention rightly gains prominence, those with established disease currently require a shift in focus from curative intent towards improved quality of life. Enter palliative care. The sheer number and complexity of needs of patients with dementia, from the physical to the psychosocial and spiritual, necessitates the engagement of a wide range of medical disciplines, nursing and allied health professionals. One of those disciplines, as highlighted in the recent Australian Royal Commission into Aged Care Quality and Safety, is palliative care. This paper shall expand upon that role in the overall context of care for those with dementia.

A qualitative study of organisational resilience in care homes in Scotland

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

Factors associated with personal recovery among psychiatric nursing home residents

WHAT IS KNOWN ABOUT THE SUBJECT?: Poor recovery will cause harm to the quality of life and well-being of residents and that the scope of influence includes the self, family and society. No study to date has investigated empowerment and the other multiple factors associated with personal recovery among psychiatric nursing home residents. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The factors associated with personal recovery are empowerment, social support and global functioning. This pioneer study contributes new evidence that personal recovery is mainly predicted by empowerment, social support and global function, with empowerment exhibiting the highest predictive value. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Strengthening empowerment in mental health nursing may contribute more to the personal recovery of psychiatric nursing home residents than improving global function or social support. Mental health professionals should shift to empowerment-oriented care to improve individuals' personal recovery, such as offering more opportunities to achieve autonomy, encouraging individuals' involvement in decision-making and promoting individuals' motivation for achieving their goals. ABSTRACT: Introduction Individuals diagnosed with mental illness have a need for recovery. No study to date has investigated empowerment and the other multiple factors associated with personal recovery among psychiatric nursing home residents. Aim The study aimed to identify the factors associated with personal recovery among psychiatric nursing home residents. Methods This was a cross-sectional study with convenience sampling. Participants were recruited from a psychiatric nursing home in Northern Taiwan between April and June 2018. Data were collected through self-reported, structured questionnaires with verified reliability and validity. Descriptive and hierarchical regression analyses were performed. The present study followed the STROBE guidelines. Results The study included 158 participants. The factors associated with recovery according to bivariate associations were religious belief, psychotic symptoms, global function, social support and empowerment. In the hierarchical regression, empowerment, social support and global function were the main predictive factors of recovery, with the explained variation reaching 40.8%. Empowerment exhibited the highest predictive value for the recovery. Implications for clinical practice Strengthening empowerment in mental health nursing may contribute more to the personal recovery of psychiatric nursing home residents than improving global function or social support.

From Warkworth House to the 21st century care homes: progress marked by persistent challenges

Long-term care homes play an essential role within health and social care. Successful measures to support older people at home for longer have led to increased prevalence of disability, frailty and cognitive impairment in those who live in care homes over the last two decades. The need for care home places is projected to increase for the next two decades. Modern care homes provide care for people who are predominantly over 80, have multiple long-term conditions, take multiple medicines, are physically dependent and live with cognitive impairment. Residents do better when services recognise the contributions of staff and care home providers rather than treating residents as individual patients living in a communal setting. There is a strong case given residents' frailty, multimorbidity and disability, that care should be structured around Comprehensive Geriatric Assessment (CGA). Care should be designed to allow opportunities for multiprofessional teams to come together for CGA, particularly if healthcare professionals are based outside care homes. Good data about care homes and residents are central to efforts to deliver high quality care-in some countries, these data are collected but not collated. Collating such data is a priority. Care home staff are under-recognised and underpaid-parity of pay and opportunity with NHS staff is the bare minimum to ensure that the best are recruited and retained in the sector. During the COVID-19 pandemic, residents and relatives have frequently been left out of decisions about policies that affect them, and better consultation is needed to deliver high quality care.

Expanding the conversation: A Person-centred Communication Enhancement Model

The intricacy and impact of human communication has long captured the attention of philosophers, scholars and practitioners. Within the realm of care and service provision, efforts to maximize outcomes through optimal person-provider communication have drawn research and clinical focus to this area for several decades. With the dawning of the person-centred care movement within healthcare, and in particular long-term care home and dementia care settings, improvement in care providers' use of person-centred communication strategies and enhancement of relationships between residents, their families and care providers are desired outcomes. Thus, several person-centred care and communication theoretical perspectives have been employed to ground study in this field. However, a comprehensive theoretical position to underpin person-centred communication in dementia and older adult research does not exist to our knowledge. To offer expansion to the theoretical work in this emerging field, a Person-Centred Communication Enhancement Model for long-term care and dementia care is proposed, as well as rationale for its development. This discussion will also provide an overview and critique of the extant philosophies, theories, frameworks and models that have been utilized in the study of person-centred communication within the context of long-term care and dementia care.

GPs’ involvement to improve care quality in care homes in the UK: a realist review

Background

Organising health-care services for residents living in care homes is an important area of development in the UK and elsewhere. Medical care is provided by general practitioners in the UK, and the unique arrangement of the NHS means that general practitioners are also gatekeepers to other health services. Despite recent focus on improving health care for residents, there is a lack of knowledge about the role of general practitioners.

Objectives

First, to review reports of research and quality improvement (or similar change management) in care homes to explore how general practitioners have been involved. Second, to develop programme theories explaining the role of general practitioners in improvement initiatives and outcomes.

Design

A realist review was selected to address the complexity of integration of general practice and care homes.

Setting

Care homes for older people in the UK, including residential and nursing homes.

Participants

The focus of the literature review was the general practitioner, along with care home staff and other members of multidisciplinary teams. Alongside the literature, we interviewed general practitioners and held consultations with a Context Expert Group, including a care home representative.

Interventions

The primary search did not specify interventions, but captured the range of interventions reported. Secondary searches focused on medication review and end-of-life care because these interventions have described general practitioner involvement.

Outcomes

We sought to capture processes or indicators of good-quality care.

Data sources

Sources were academic databases [including MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature, PsycInfo® (American Psychological Association, Washington, DC, USA), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and Cochrane Collaboration] and grey literature using Google Scholar (Google Inc., Mountain View, CA, USA).

Methods

Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were followed, comprising literature scoping, interviews with general practitioners, iterative searches of academic databases and grey literature, and synthesis and development of overarching programme theories.

Results

Scoping indicated the distinctiveness of the health and care system in UK and, because quality improvement is context dependent, we decided to focus on UK studies because of potential problems in synthesising across diverse systems. Searches identified 73 articles, of which 43 were excluded. To summarise analysis, programme theory 1 was ‘negotiated working with general practitioners’ where other members of the multidisciplinary team led initiatives and general practitioners provided support with the parts of improvement where their skills as primary care doctors were specifically required. Negotiation enabled matching of the diverse ways of working of general practitioners with diverse care home organisations. We found evidence that this could result in improvements in prescribing and end-of-life care for residents. Programme theory 2 included national or regional programmes that included clearly specified roles for general practitioners. This provided clarity of expectation, but the role that general practitioners actually played in delivery was not clear.

Limitations

One reviewer screened all search results, but two reviewers conducted selection and data extraction steps.

Conclusions

If local quality improvement initiatives were flexible, then they could be used to negotiate to build a trusting relationship with general practitioners, with evidence from specific examples, and this could improve prescribing and end-of-life care for residents. Larger improvement programmes aimed to define working patterns and build suitable capacity in care homes, but there was little evidence about the extent of local general practitioner involvement.

Future work

Future work should describe the specific role, capacity and expertise of general practitioners, as well as the diversity of relationships between general practitioners and care homes.

Study registration

This study is registered as PROSPERO CRD42019137090.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 20. See the NIHR Journals Library website for further project information.

Giving midwives a voice - Qualitative perspectives of an 'empowering decision-making workshop'

AIM/OBJECTIVE

To establish midwives' perceptions of the value of workshops designed to empower their decision-making and leadership skills using validated midwifery clinical reasoning frameworks and appreciative inquiry methods.

BACKGROUND

The medical lens of childbirth can disempower women and midwives. Midwives often face challenges navigating their role as autonomous practitioners and advocates for shared decision-making, particularly when there is tension between women's wishes, governance frameworks and organisational requirements. This can lead to 'Midwifery Abdication' and/or the midwifery voice being silenced.

DESIGN/METHODS

Appreciative inquiry, involving qualitative analysis of 31 midwives' personal reflections during 'Empowering Midwives' Decision-Making' workshops. Standards for reporting qualitative research (SRQR criteria) guided the preparation of this manuscript.

RESULTS

Decision-making tools and 'appreciative' strategies can strengthen leadership attributes, enhance feelings of empowerment and deepen understanding. Reflecting on 'Midwifery Abdication' was perceived as confronting. Workshop activities offered understanding the reasons why 'Midwifery Abdication' may or may not occur. One overarching, key theme was identified: 'Finding my midwifery voice'. This theme encompassed three sub-themes: 'I am not alone', 'Using leadership to promote collaboration to effect change' and 'An onward journey of enlightenment and empowerment'.

CONCLUSION

Midwives need to find their voice and develop skills in both clinical reasoning and transformative reflection. Workshops, using Appreciative Inquiry approaches, that focused on reflection, clinical decision-making and 'Midwifery Abdication', facilitate this and may create feelings of reunification in midwives and rejuvenate inherent passion for the profession.

RELEVANCE TO CLINICAL PRACTICE

Sharing feelings around providing care in the often-contested space that is advocating for women using midwifery philosophy may provide relief from moral distress and a sense of shared identity desperately sought after by midwives struggling to navigate the increasingly complex terrain of maternity care. Findings encourage the need for further discussions around strengthening midwifery leadership which may be achievable using Appreciative Inquiry frameworks and approaches.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review

BACKGROUND

Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

OBJECTIVES

To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

DESIGN

A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

SETTING

Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

RESULTS

66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

CONCLUSION

Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Supporting good quality, community-based end-of-life care for people living with dementia: the SEED research programme including feasibility RCT

Background

In the UK, most people with dementia die in the community and they often receive poorer end-of-life care than people with cancer.

Objective

The overall aim of this programme was to support professionals to deliver good-quality, community-based care towards, and at, the end of life for people living with dementia and their families.

Design

The Supporting Excellence in End-of-life care in Dementia (SEED) programme comprised six interlinked workstreams. Workstream 1 examined existing guidance and outcome measures using systematic reviews, identified good practice through a national e-survey and explored outcomes of end-of-life care valued by people with dementia and family carers (n = 57) using a Q-sort study. Workstream 2 explored good-quality end-of-life care in dementia from the perspectives of a range of stakeholders using qualitative methods (119 interviews, 12 focus groups and 256 observation hours). Using data from workstreams 1 and 2, workstream 3 used co-design methods with key stakeholders to develop the SEED intervention. Worksteam 4 was a pilot study of the SEED intervention with an embedded process evaluation. Using a cluster design, we assessed the feasibility and acceptability of recruitment and retention, outcome measures and our intervention. Four general practices were recruited in North East England: two were allocated to the intervention and two provided usual care. Patient recruitment was via general practitioner dementia registers. Outcome data were collected at baseline, 4, 8 and 12 months. Workstream 5 involved economic modelling studies that assessed the potential value of the SEED intervention using a contingent valuation survey of the general public (n = 1002). These data informed an economic decision model to explore how the SEED intervention might influence care. Results of the model were presented in terms of the costs and consequences (e.g. hospitalisations) and, using the contingent valuation data, a cost–benefit analysis. Workstream 6 examined commissioning of end-of-life care in dementia through a narrative review of policy and practice literature, combined with indepth interviews with a national sample of service commissioners (n = 20).

Setting

The workstream 1 survey and workstream 2 included services throughout England. The workstream 1 Q-sort study and workstream 4 pilot trial took place in North East England. For workstream 4, four general practices were recruited; two received the intervention and two provided usual care.

Results

Currently, dementia care and end-of-life care are commissioned separately, with commissioners receiving little formal guidance and training. Examples of good practice rely on non-recurrent funding and leadership from an interested clinician. Seven key components are required for good end-of-life care in dementia: timely planning discussions, recognising end of life and providing supportive care, co-ordinating care, effective working with primary care, managing hospitalisation, continuing care after death, and valuing staff and ongoing learning. Using co-design methods and the theory of change, the seven components were operationalised as a primary care-based, dementia nurse specialist intervention, with a care resource kit to help the dementia nurse specialist improve the knowledge of family and professional carers. The SEED intervention proved feasible and acceptable to all stakeholders, and being located in the general practice was considered beneficial. None of the outcome measures was suitable as the primary outcome for a future trial. The contingent valuation showed that the SEED intervention was valued, with a wider package of care valued more than selected features in isolation. The SEED intervention is unlikely to reduce costs, but this may be offset by the value placed on the SEED intervention by the general public.

Limitations

The biggest challenge to the successful delivery and completion of this research programme was translating the ‘theoretical’ complex intervention into practice in an ever-changing policy and service landscape at national and local levels. A major limitation for a future trial is the lack of a valid and relevant primary outcome measure to evaluate the effectiveness of a complex intervention that influences outcomes for both individuals and systems.

Conclusions

Although the dementia nurse specialist intervention was acceptable, feasible and integrated well with existing care, it is unlikely to reduce costs of care; however, it was highly valued by all stakeholders (professionals, people with dementia and their families) and has the potential to influence outcomes at both an individual and a systems level.

Future work

There is no plan to progress to a full randomised controlled trial of the SEED intervention in its current form. In view of new National Institute for Health and Care Excellence dementia guidance, which now recommends a care co-ordinator for all people with dementia, the feasibility of providing the SEED intervention throughout the illness trajectory should be explored. Appropriate outcome measures to evaluate the effectiveness of such a complex intervention are needed urgently.

Trial registration

Current Controlled Trials ISRCTN21390601.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research, Vol. 8, No. 8. See the NIHR Journals Library website for further project information.

The Impact of Implementing a Namaste Care Intervention in UK Care Homes for People Living with Advanced Dementia, Staff and Families

Care homes can struggle to provide optimal care for residents with advanced dementia. Namaste Care provides a structured daily programme of physical, sensory and emotional care delivered by regular care workers. A three-year, mixed method process study of implementation and impact created a manualised Namaste Care Intervention for UK care homes (NCI-UK). This article reports on the impact of NCI-UK delivered consistently in five care homes for 12–24 weeks. Impact for residents was assessed using, pre-post data, showing significant positive effects for QUALID (t = 2.92, p = 0.01, n = 31) and CMAI (t = 3.31, p = 0.002, n = 32), alongside many qualitative examples of positive impacts on wellbeing, responsiveness and communication. Pre-post staff questionnaire data (n = 20) were not significant. Qualitative data indicated that NCI-UK is a positive staff experience, providing sense of purpose, improved wellbeing and relationships. The care homes reported benefiting from implementing NCI-UK in terms of reputation and quality improvement. Family interviews were also positive, relating to seeing the difference, improving relationships and being involved. NCI-UK can therefore be recommended as an impactful intervention for residents, staff and families.

Living With Cognitive Impairment in China: Exploring Dyadic Experiences Through a Person-Centered Care Lens

China has experienced a substantial increase in the number of older adults with dementia and milder forms of cognitive impairment. Being spouses of Persons with cognitive impairment (PWCI) and living with them for several decades does not necessarily mean that it is easier for them to provide person-centered care and maintain a valued and healthy relationship. The current study explored how elements of PCC, as operationalized by the Senses Framework, operate or fail to operate in the dyadic experiences of PWCI and their spousal care partners within the socio-cultural context of China. Our findings suggest that PWCI and their spouses experience the six senses through the person-centeredness in their daily interactions with each other. It also indicated successes and challenges to being person-centered early in the disease and identified their unmet needs as well as barriers and facilitators to improve their well-being.

Nurses and midwives teaching in the academic environment: An appreciative inquiry

BACKGROUND

The past two decades has seen significant change in nursing and midwifery education in Australia. Although, regulatory documents explicate expectations of teaching, and supervising in the context of being a nurse or midwife, the move from hospital-based to higher education learning nessitated a change in how students receive their education and who provides it. The quality of teaching by nurse or midwife academics is subject to the academic's ability to transition from a clinical educator to academic.

OBJECTIVE

To explore the experiences of nurse and midwife academics teaching in the academic environment.

DESIGN

Appreciative Inquiry (AI) was used to explore the experiences of academics teaching final year nursing and midwifery students.

SETTING

Two regional universities in Australia.

PARTICIPANTS

Seven nursing and midwifery academics teaching a unit of study focusing on mentorship, leadership and teaching.

METHODS

Narrative data from interviews conducted using AI were collected, transcribed and analysed to produce themes.

RESULTS

Three key themes were identified; 'Feeling valued', 'Feeling safe' and 'Having connections'. These themes and related subthemes impacted teaching experiences and role transition from experienced clinician to academic.

CONCLUSION

Nursing and midwifery academics would benefit from organisational support in their role transition from clinician to academic. Further research is crucial regarding initiatives that can support academics to feel safe, valued and connected when teaching the next generation of nurses and midwives.

Correlates of affiliate stigma among family caregivers of people with mental illness: A systematic review and meta-analysis

WHAT IS KNOWN ON THE SUBJECT?: A growing body of qualitative and quantitative research has investigated the experiences of affiliated stigma for family members of PWMI. Some findings are contradictory and have not been considered systematically. WHAT DOES THE PAPER ADDS TO EXISTING KNOWLEDGE?: Family caregivers of PWMI may encounter affiliate stigma, but no systematic review or meta-analysis has been conducted to evaluate affiliate stigma among them. We identified eight variables significantly related to affiliate stigma among caregivers of PWMI. The findings can be used to help clinical practice to develop health promotion and prevention strategies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Affiliate stigma was prevalent among the family caregivers of PWMI and is important for clinicians to consider. Health-focused interventions for family caregivers can mediate the impact of affiliated stigma through provision of social support by practitioners, such as respite care based on the "Senses Framework," self-help groups and online support program. And the caregivers of PWMI might benefit from further support (e.g., psychoeducation) to improve their knowledge about mental illness. ABSTRACT: Introduction Many studies have investigated the correlates of affiliate stigma among family caregivers of people with mental illness (PWMI). Thus far, no systematic review or meta-analysis has been conducted to synthesize these results. Aims/Question This review aims to identify the correlates of affiliate stigma among family caregivers of PWMI. Method We searched four databases including PubMed, PsycINFO, EMBASE and Web of Science for studies that investigated the association of affiliate sigma with socio-demographic, psychosocial and disease-related factors. Results Twenty-two studies including 3,381 participants met the inclusion criteria. Eighteen variables were included for the meta-analysis. For disease-related characteristics, only "disease attribution" and "care time/day" were associated with affiliate stigma. For psychosocial characteristics, "support from others," "burden," "depression," "stress," "distress" and "face concern" were related to affiliate stigma. Discussion This review is the first to assess the association of affiliate stigma with other characteristics of interest. However, the findings are limited due to a very small number of studies. Researchers should conduct in-depth study in this area and improve the quality of the literature. Implications for practice Health-focused interventions for family caregivers such as respite care, self-help groups, online support program and psychosocial education can mediate the impact of affiliated stigma.

The use of life stories and its influence on persons with dementia, their relatives and staff - a systematic mixed studies review

Background

Dementia is an important predictor of nursing home admissions. Due to progressive dementia symptoms, over time it becomes difficult for persons with dementia to communicate their wishes and participate in decisions concerning their everyday lives. Their well-being, sense of dignity, integrity and personhood are at risk. The persons’ life stories have been highlighted as particularly important in dementia care and are referred to as seeing the person beyond the dementia. The aim of this study was to explore and describe the use of life stories and its influence on persons with dementia living in nursing homes, their relatives and staff.

Methods

A systematic mixed studies review was conducted. The literature searches were performed in the following databases: CINAHL, PubMed and PsycINFO and the Cochrane library, as well as by hand searching references in the studies included. An updated search was performed eight months after the first search. Data was synthesised inspired by integrative analysis.

Results

Three studies using quantitative design and two studies (presented in three papers) using qualitative design representing research from 2006 to 2015 were included in the review. Life stories generally had a positive influence on the persons with dementia, their relatives, and staff. The use of life stories might contribute to ‘Maintenance of the person with dementia as a whole person rather than a demented patient’. On the other hand, enabling persons with dementia to tell their own story could be a challenge. For the staff it could be challenging when sensitive information emerged uninvited. Involving relatives could also be difficult as to whose story were uncovered.

Conclusions

The use of person’s life story might be of significance, but there is not enough evidence to make any statement about its importance as the research is scarce. Studies, including randomised controlled trials, are needed to measure the impact of life story work on the physiological and psychological aspects of persons with dementia, and also how it influences their relatives and staff.

Person-centred care dialectics-Inquired in the context of palliative care

Although a widely used concept in health care, person-centred care remains somewhat ambiguous. In the field of palliative care, person-centred care is considered a historically distinct ideal and yet there continues to be a dearth of conceptual clarity. Person-centred care is also challenged by the pull of standardization that characterizes much of health service delivery. The conceptual ambiguity becomes especially problematic in contemporary pluralistic societies, particularly in the light of continued inequities in healthcare access and disparities in health outcomes. Our aim was to explicate premises and underlying assumptions regarding person-centred care in the context of palliative care with an attempt to bridge the apparently competing agendas of individualization versus standardization, and individuals versus populations. By positioning person-centredness in relation to the hermeneutics of the self according to Paul Ricœur, dialectics between individualization and standardization, and between individuals and populations were constructed. The competing agendas were related in a dialectic manner in the way that population health is of importance for the individual, and standardization is of importance for the population. The analysis suggests that person-centred care is an ethical stance, which gives prominence to both suffering and capability of the individual as a person. The dialectic analysis points towards the importance of extending person-centred care to encompass population and societal perspectives and thereby avoiding a problematic tendency of affiliating person-centred care with exclusively individualistic perspectives. Considerations for person-centred palliative care on micro-, meso- and macrolevels conclude the paper.

The Influence of Organizational Systems on Information Exchange in Long-Term Care Facilities: An Institutional Ethnography

Person-centered care is heavily dependent on effective information exchange among health care team members. We explored the organizational systems that influence resident care attendants' (RCAs) access to care information in long-term care (LTC) settings. We conducted an institutional ethnography in three LTC facilities. Investigative methods included naturalistic observations, in-depth interviews, and textual analysis. Practical access to texts containing individualized care-related information (e.g., care plans) was dependent on job classification. Regulated health care professionals accessed these texts daily. RCAs lacked practical access to these texts and primarily received and shared information orally. Microsystems of care, based on information exchange formats, emerged. Organizational systems mandated written exchange of information and did not formally support an oral exchange. Thus, oral information exchanges were largely dependent on the quality of workplace relationships. Formal systems are needed to support structured oral information exchange within and between the microsystems of care found in LTC.

How To Build an Integrated Neighborhood Approach to Support Community-Dwelling Older People?

BACKGROUND

Although the need for integrated neighborhood approaches (INAs) is widely recognized, we lack insight into strategies like INA. We describe diverse Dutch INA partners' experiences to provide integrated person- and population-centered support to community-dwelling older people using an adapted version of Valentijn and colleagues' integrated care model. Our main objective was to explore the experiences with INA participation. We sought to increase our understanding of the challenges facing these partners and identify factors facilitating and inhibiting integration within and among multiple levels.

METHODS

Twenty-one interviews with INA partners (including local health and social care organizations, older people, municipal officers, and a health insurer) were conducted and subjected to latent content analysis.

RESULTS

This study showed that integrated care and support provision through an INA is a complex, dynamic process requiring multilevel alignment of activities. The INA achieved integration at the personal, service, and professional levels only occasionally. Micro-level bottom-up initiatives were not aligned with top-down incentives, forcing community workers to establish integration despite rather than because of meso- and macro-level contexts.

CONCLUSIONS

Top-down incentives should be better aligned with bottom-up initiatives. This study further demonstrated the importance of community-level engagement in integrated care and support provision.

Care Perceptions among Residents of LTC Facilities Purporting to Offer Person-Centred Care

Cette étude a exploré d’une manière qualitative comment les résidents des maisons de soins de longue durée (SLD) pensent et s’adaptent aux soins qu’ils reçoivent. Nous avons interrogé et observé un groupe délibérément choisi parmi des personnes âgées dans sept etablissements qui prétendent fournir des soins centrés sur la personne. Les descriptions interprétatives de la part de 43 entrevues personnelles avec 23 participants correspondaient a une réponse à la question: Comment les habitants perçoivent-ils les soins rendus dans les établissements de SLD qui se présentent comme offrant des soins centrés sur la personne? Trois thèmes dominants sont ressortis: (1) l’environnement bienveillant; (2) la préservation de la dignité; et (3) le maintien de l’autonomie personnelle. Les participants étaient sensibles à la charge de travail du personnel infirmier, mais se sentaient éloignés du personnel. Les participants ont donné des exemples de mauvais soins et une manque d’empathie, des indignités humains et des violations de l’autonomie personnelle causées par les politiques institutionnelles qu’ils se sentaient inhibiter leur capacité à recevoir des soins selon leurs propres préférences. En général, ils ont contesté les allégations de soins centrés sur la personne, mais ils s’y sont adaptés pour faire face à un environnement qui menace leur dignité et leur autonomie.

Dignity in long-term care: An application of Nordenfelt's work

BACKGROUND

The concept of dignity is recognised as a fundamental right in many countries. It is embedded into law, human rights legislation and is often visible in organisations' philosophy of care, particularly in aged care. Yet, many authors describe difficulties in defining dignity and how it can be preserved for people living in long term care.

OBJECTIVES

In this article, Nordenfelt's 'four notions of dignity' are considered, drawing on research literature addressing the different perspectives of those who receive, observe or deliver care in the context of the long-term care environment.

METHODS

A review of the literature was undertaken using the terms 'nursing homes', 'residential care' or 'long-term care'. The terms were combined and the term 'human dignity' was added. A total of 29 articles met the inclusion criteria from the United Kingdom (14), United States (2), Australia (1), Sweden (3), Hong Kong (2), Norway (3), Nordic (1), Taiwan (1), Netherlands (1). Ethical Considerations: Every effort has been made to ensure an unbiased search of the literature with the intention of an accurate interpretation of findings.

DISCUSSION

The four notions of dignity outlined by Nordenfelt provide a comprehensive description of the concept of dignity which can be linked to the experiences of people living in long-term care today and provide a useful means of contextualising the experiences of older people, their families and significant others and also of staff in long-term care facilities. Of particular interest are the similarities of perspectives of dignity between these groups. The preservation of dignity implies that dignity is a quality inherent in us all. This links directly to the exploration and conclusions drawn from the literature review. Conversely, promoting dignity implies that dignity is something that can be influenced by others and external factors. Hence, there are a number of implications for practice.

CONCLUSION

We suggest that two of Nordenfelt's notions, 'dignity of identity' and 'dignity of Menschenwüde', are a common thread for residents, family members and staff when conceptualising dignity within long-term care environments.

The shared experience of caring: a study of care-workers' motivations and identifications at work

This article presents an analysis of long-term care-workers' work motivation that examines the way this is shaped by the social contexts in which they operate. We conducted a thematic analysis of 19 in-depth interviews with care-workers. Three core themes were identified as underpinning their motivation: those of ‘fulfilment’, ‘belonging’ and ‘valuing’, and together these contributed to a central theme of ‘pride’. We also found an overarching theme of ‘shared experience’ to be integral to the way in which care-workers made sense of their motivation and work experience. We draw on the social identity approach to provide a conceptual framework through which to understand how this shared experience shapes care-workers' motivation and the quality of care they deliver. In particular, we note the importance that care-workers' attach to their relationships with clients/patients and highlight the way in which this relational identification shapes their collective identification with their occupation and organisation and, through this, their motivation.

Focus on Feeding! Evaluation of a framework for maximizing mealtime in aged care facilities

Unintentional weight loss is a health risk for residents of aged care facilities, a concern for families and places demands on nursing staff. An existing weight loss framework to assess and manage residents' weight developed by a multidisciplinary team was implemented and evaluated with nurses and residents in aged care facilities within an area health service of Sydney, Australia. Thematic analysis generated seven binary concepts relating to relational, procedural, behavioural, physical, psychological, environmental and temporal aspects of feeding assistance provided by nurses to residents. Theoretical sampling was applied to the literature confirming those concepts which were organized as a model of feeding assistance labelled the Focus on Feeding! Decision Model. Nurses can play a pivotal role in the assessment of feeding difficulty and implementation of innovative mealtime programs. The Model aims to promote nurses' critical thinking and decision-making to improve nutritional intake of residents and avoid preventable weight loss.

Guiding design of dementia friendly environments in residential care settings: Considering the living experiences

In the past twenty years, the importance of the physical and social environments in supporting the person with dementia has gained a much higher profile in dementia care. Despite efforts to move aged care away from the medical model to a more balanced social model of care, we still struggle with the dominance of an institutional context which impedes individuality and choice. This article argues that the experience of the person with dementia should frame the perspective brought to built design and the philosophy of care — in essence, `looking out from the inside'. Shifting the emphasis from condition to experience encourages the culture change needed to create environments that allow the person with dementia to be an active participant in everyday life rather than a passive recipient of care. Based on the development of a resource for residential and respite facilities in Australia, seven living experiences are identified: the presentation of self-experience, eating experience, personal enjoyment experience, bedroom experience, family and community connections experience, end-of-life experience and the staff experience. Each is discussed to show how consideration of the living experiences provides a way to focus thinking for design of the built environment to practically support the person with dementia, thereby addressing the wider spectrum of issues in creating a dementia friendly physical and social environment from the perspective of the person with dementia.

Discipline in chaos: Foucault, dementia and aging in India

In India, care work for people in late-stage dementia is primarily conducted in the home. Using source material from urban India and drawing on Foucauldian theory, we illustrate the significance of three power/knowledge scripts in this context: social and cultural notions of acceptable, public bodies; medicalized forms of care; and the cultural contexts of the individual caregivers. The caregiver is the embodiment of these discourses and is charged with the task of mapping discipline onto inherently undisciplinable bodies. A tension exists between the caregiver's struggle to contain the unruliness of the person with dementia and, simultaneously, to act as a broker between the world of the care-recipient and the social world. We conclude that although the caregiver is the starting point for the exercise of discipline, the three power/knowledge scripts that inform care work are as much about surveying, routinizing and mobilizing caregivers' bodies as they are about disciplining the bodies of people with dementia.