Tacit knowledge of caring and embodied selfhood

Sitting in Wait: Everyday Caregiving Practices for People with Dementia in Rural South Africa

Practice theories offer potential to reveal, understand, and attribute value to the everyday thoughts and actions of dementia caregivers. Drawing on ethnographic data from research in rural South Africa, on everyday dementia care practices, we highlight the profound importance of mundane practices - especially "sitting in wait" - for optimizing wellbeing of people with dementia who are cared for at home. We draw attention to the structural drivers of homebased (informal) care, which is underpinned by state inaction. This situates the act of sitting in wait as both an act of care and an embodied form of structural powerlessness.

Exploring tacit knowledge based on an expert nurse's practice for stroke patients

This study explored tacit knowledge based on an expert nurse's practice who cares for stroke patients by using the hermeneutic phenomenological approach. The participant ('Ms. A') was a nursing researcher and college faculty member involved in the education of advanced practice nurses; her specialty was stroke rehabilitation nursing. She was asked to describe the meaning and value she gained from her memorable nursing experiences. Four interviews-approximately 1 h each-were conducted, and the associated data were interpreted together with the participant based on the method of interpretive circulation. Notably, the analysis was ended when a fusion of horizons was recognized. The participant recalled her nursing experiences based on six model cases. During the analysis, the following five elements were extracted: [belief in the ability of vulnerable people to survive]; [being together]; [respect for human dignity]; [preparedness to respond to and bear suffering together]; and [theoretical knowledge base approaches true understanding of patient experience]. Further, the nursing model-the Roy Adaptation Model-utilized by Ms. A in the process of recognizing humans as whole beings was deeply interpreted and implemented as a guideline for her implicit advanced practice. Moreover, her deep understanding and utilization of theoretical knowledge base also built the foundation for her implicit advanced practice. In conclusion, Ms. A's tacit knowledge and the elements support the process of tacit knowledge acquisition. Her narratives, hermeneutic attitude as an interpreter, and learning attitude throughout interaction with others will strongly help her knowledge development. We intend to continue the study with multiple participants and explore the structure of tacit knowledge possessed by advanced practitioners. Future endeavours will include the development of a tacit knowledge learning strategy.

Tacit knowledge in dyads of persons with profound intellectual and multiple disabilities and their caregivers: An interpretative literature study

BACKGROUND

Caring for persons with profound intellectual and multiple disabilities (PIMD) demands specific expertise. Tacit knowledge seems to play an important role, but little is known about its nature, including what is necessary for its development and transfer.

AIM

To gain understanding of the nature and development of tacit knowledge between persons with PIMD and their caregivers.

METHOD

We conducted an interpretative synthesis of literature on tacit knowledge in caregiving dyads with persons with PIMD, persons with dementia or infants. Twelve studies were included.

RESULTS

Tacit knowledge is about caregivers and care-recipients becoming sensitive and responsive to each other's cues and together crafting care routines. Learning takes place in a constant process of action and response that transforms those involved.

CONCLUSION

Building tacit knowledge together is necessary for persons with PIMD to learn to recognise and express their needs. Suggestions are made for ways to facilitate its development and transfer.

Using the performance arts to address a "methods gap" in dementia research

Introduction: Traditional methods of research have frequently failed to accommodate the communication difficulties experienced by a significant proportion of residents living in long-term care. In dementia research, specifically, there is cause for more collaborative, creative ways of working.Methods: The Linking Lives Through Care study is a performance-based narrative inquiry that will take place in a long-term care setting and will bring together all three members of the care triad - residents who are living with dementia, family members and personal support workers - to explore relational care from multiple positions and perspectives.Discussion: In this article, we discuss the design choices and creative measures taken to ensure a more inclusive research environment, specifically for those participants who are cognitively frail and/or may find it difficult to express their views using just words.

Perspectives of Multidisciplinary Professional Teams during Assessment Processes for ATD Selection in the Japanese Public Provision System

Selection of assistive technology devices (ATDs), which are imperative for persons with disabilities to improve their quality of life, requires collaboration of users and multidisciplinary professionals. However, it is still unknown how to design and implement an adequate collaborative work flow and a professional team. Under Japanese governmental ATD provision system, based on the application by clients, ATDs are mainly selected through collaborative processes with the clients and health professionals in public organizations, rehabilitation counseling centers (RCCs). By employing qualitative study methods in this study, we investigated the ATD selection process in which health professionals in RCCs collaboratively assess clients with physical disabilities so as to support them in selecting the adequate ATDs. To identify the perspectives required for ATD selection completely, the assessment processes were recorded and analyzed with a pseudo setting in two RCCs. Content analysis of the conversations between the client and professionals revealed the characteristics of the information exchanged in the assessment processes. A total of 760 assessment items were identified, thus indicating a broad array of interest. Despite the richness of information collected for the assessment, half of the assessment items did not have corresponding items in the documents that were employed during the prescription process. Thematic analysis of the interviews that followed revealed the common values and collaborative processes in ATD selection, which were shared and elaborated among the staff in daily social interactions. To facilitate implementation of ATD provision in various areas with few resources, it may be effective to convert this tacit-to-tacit knowledge sharing into a more explicit sharing by promoting analyses of good practices.

Embodiment and personal identity in dementia

Theories of personal identity in the tradition of John Locke and Derek Parfit emphasize the importance of psychological continuity and the abilities to think, to remember and to make rational choices as a basic criterion for personhood. As a consequence, persons with severe dementia are threatened to lose the status of persons. Such concepts, however, are situated within a dualistic framework, in which the body is regarded as a mere vehicle of the person, or a carrier of the brain as the organ of mental faculties. Based on the phenomenology of embodiment, this paper elaborates a different approach to personal identity in dementia. In this perspective, selfhood is primarily constituted by pre-reflective self-awareness and the body memory of an individual, which consists in the embodiment and enactment of familiar habits, practices and preferences. After describing the different types of body memory, the paper develops a phenomenology of dementia as a loss of reflexivity and meta-perspective. This is contrasted with the preservation of individual forms of body memory even in the later stages of the illness. The ethical consequences of an embodied approach to dementia are outlined. A final look is given to narrativistic and constructionist concepts of the self in dementia.

Gender and dementia national strategy policymaking: Working toward health equity in Canada through gender-based analysis plus

This article discusses the results of a content and critical discourse analysis of Canadian federal policy documentation relating to the development of a national Canadian dementia strategy. These documents span from 2013 and focus upon Canadian federal policy directives and directions up to the release, and including the release, of a national strategy in June 2019. The analyses, supplemented by a subtextual examination of these documents guided by Bacchi's (2012) "What's the Problem Represented to be?" framework, focuses upon the treatment of gender in policy documentation and the specific gender related policy framework, known as GBA+ (gender-based analysis and intersectionality), which is intended to bring about health equity to disadvantaged groups. As women, particularly, working class women and their carers, as well as women with additional intersecting factors, such as being lesbian or bisexual, are less likely to receive the dementia related care and services they need, precipitating a premature move to residential care, GBA+ is an essential policy framework in the attempt to address these inequities. However, findings point to a superficial treatment of gender, GBA and GBA+ in federal policy documents and lack a meaningful invocation of women's gendered and intersectional lived experiences of dementia. Additionally, the Canadian federal government's Dementia Strategy for Canada: Together We Aspire (2019) is grounded in a rendition of citizenship that do not work to unearth the complex relationships between citizenship, old age, gender and intersectional factors. As a result, the Dementia Strategy for Canada: Together We Aspire (2019) presents a version of citizenship that homogenizes older adults and prevents representations of older adults as diverse, complex and continually changing groupings. Therefore, inspired by Bartlett et al. (2018), I advocate for the application of a feminist and intersectional citizenship lens in Canadian federal dementia-related policymaking documentation going forward.

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.

(In)visible materialities in the context of dementia care

Seemingly mundane materialities are intertwined with important, but often neglected, care interactions. It has been argued that if healthcare professionals paid more attention to the roles materialities can have, everyday routines could become important occasions for care. In response to such proposals, we argue that it is relevant to examine how materialities are currently understood. In this article, we explore materialities as part of work in a dementia unit. Using abstracted illustrations of everyday materialities to elicit reflections, we conducted 11 individual interviews with certified nursing assistants. Through phenomenographic analysis we explain our findings as three different categories conceptualising understandings of materialities as: 'tools for care', 'a set of principles for care' and 'caring relationships'. Our analysis indicates that understanding materialities as instruments was reinforced and made visible through the healthcare organisation while understanding materialities as part of specific relationships with residents appeared informal and less visible. How materialities were understood seemed to have several implications for residents. While care practices could benefit from nursing assistants' abilities to alternate between ways of understanding materialitites, such competence seemed dependent on how professional care was organised, structured and materialised.

Doença de Alzheimer e xamanismo: diálogos (im)possíveis

Resumo Relacionar os processos demenciais ao tornar-se louco ou ser outra pessoa, estar possuído, foi algo que encontrei em cenas e relatos de meu material de campo. É numa tentativa de compreender o que está em jogo nesse “devir outro” que faço um diálogo entre doença de Alzheimer e xamanismo enquanto fenômenos que lidam com processos de transformação em situações-limite, como doença, infortúnio, desordem, morte. Tal diálogo, que percorre aproximações e distanciamentos, permite pensar nos deslocamentos das noções de pessoa, doença e realidade entre os diferentes sujeitos e campos. Ao trazer a discussão sobre xamanismo como um valor de contraste, uma analogia “boa pra pensar”, busquei outras referências para a compreensão da doença de Alzheimer não só como diagnóstico, mas também como experiência, modo de vida - um “mundo outro” - , mostrando como o discurso biomédico da “dissolução de self” se fundamenta em uma noção específica de pessoa.

Knowledge and expertise in care practices: the role of the peer worker in mental health teams

Our research examines how different forms of knowledge and expertise are increasingly important in caring for people experiencing mental illness. We build on theoretical developments regarding multiple ontologies of knowing about illness. We examine how experiential knowledge of mental health problems, learned by being subject to illness rather than through objective study, is enacted in mental healthcare teams. We focus on Peer Workers (PW), individuals who have lived experience of mental health problems, and who contribute knowledge and expertise to mental health care within multidisciplinary healthcare teams. Our longitudinal study was undertaken over 2 years by a multidisciplinary team who conducted 91 interviews with PW and other stakeholders to peer support within a comparative case study design. We show how workers with tacit, experiential knowledge of mental ill health engaged in care practice. First, we show how subjective knowing is underpinned by unique socialisation that enables the development of shared interactional spaces. Second, we point to how the situated nature of subjective knowing is uniquely embedded in time and space and allows for the alignment of embodied knowledge with trajectories of care. Third, we provide insight into how subjective forms of expertise might be incorporated into multidisciplinary care.

Stronger together: learning from an interdisciplinary dementia, arts and well-being network (DA&WN)

Background This paper reports on the learning from a 12-month interdisciplinary project (Dementia, Arts and Wellbeing Network- DA&WN) and its activities. These featured a series of four workshops on dance, visual art, theatre and music. The network was comprised of clinicians, academics, creative practitioners and people with lived experience of dementia and their carers. Methods The workshops were designed to draw out tacit knowledge about well-being in dementia through an action-based learning and research approach. This included, guided activities combined with reflective group discussions, visual documentation and baseline and follow-up questionnaires. Results Outcomes included new collaborations between group members, changes in creative practice for artists, and active and sustained involvement of people living with dementia and their carers in similar opportunities and participatory research. Conclusion This participatory and inclusive workshop model should be considered to develop and enhance interdisciplinary activities in dementia care.

Barriers to Staff Involvement in End-of-Life Decision-Making for Long-Term Care Residents with Dementia

ABSTRACTAlthough providing direct care to residents with dementia, long-term care (LTC) home staff of registered nurses', registered practical nurses', and personal support workers' involvement in end-of-life decision-making is rarely acknowledged. The purpose of this study was to examine barriers and facilitators to LTC home staff involvement in end-of-life decision-making for people with advanced dementia. We report on the barriers to staff involvement in decision-making. Using an interpretive descriptive design, four major barriers to staff involvement in decision-making were identified: (a) the predominance of a biomedical model of care; (b) a varied understanding of a palliative approach; (c) challenging relationships with families; and (d) a discomfort with discussing death. Findings suggest that the predominant biomedical model in LTC homes, while important, must be imbued with a philosophy that emphasizes relationships among residents with dementia, family and staff.

Preparedness of representatives for people with dementia in a self-directed program

Representatives enact their role as decision-making partners across the intersection of participant direction (PD) and dementia care. Self-rated preparedness for key dimensions of the role endorsed by a panel of experts in PD and dementia was assessed by telephone survey of 30 representatives of persons with dementia in a PD program. The sample (daughters 60%; Black 50%; rural 70%) was diverse in length of time in the role and additional responsibilities. They represented participants with moderate to advanced dementia and ≥ two additional chronic illnesses. Overall preparedness scores were in the pretty well to very well prepared range, with variation across dimensions and between individuals. Preparedness varied according to what has to be done day-to-day in dynamic or unpredictable situations, gauging decisional capacity, anticipating changing needs, ensuring safety, supporting a dementia-capable care team and negotiation. Stress was related to having a safety net of capable back-up supports and dementia care literacy. Areas of strength, individual variation and particular challenges along the trajectory of representing can guide development of support counselor interventions to provide representatives with tailored training and resources as they enable the benefits of PD for persons with dementia.

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.

How do care staff in residential aged care facilities conceptualise their non-verbal interactions with residents with dementia and what relevance has this for how residents' preferences and capacity for decision-making are understood?

This paper considers the significance of how staff in residential aged care facilities interpret the non-verbal communication and behaviour of residents vis-a-vis their assessments of residents' preferences and ability to participate in decision-making. It highlights the risks associated with staff members' failure to interpret residents' non-verbal communication and behaviour with reference to residents' backgrounds and prior experiences. It also considers how non-verbal communication implemented by staff may impact residents' emotional state and, as a consequence, decision-making abilities. Drawing on interview data with aged care staff from Queensland and Victoria, it demonstrates that care staff in residential facilities appear to rely heavily on non-verbal signals in assessing the decision-making capacity and preferences of residents with dementia. It also indicates that many staff fail to consider residents' non-verbal communication and behaviour with due consideration of residents' individual histories.

Integrating Citizenship, Embodiment, and Relationality: Towards a Reconceptualization of Dance and Dementia in Long-Term Care

Dance, as aesthetic self-expression, is a unique arts-based program that combines the physical benefits of exercise with psychosocial therapeutic benefits. While dance has also been shown to support empowerment, meaningful self-expression, and pleasurable experience, it is rarely adopted to support these aspects of engagement in the context of dementia care. The instrumental reduction of dance to its application as a therapeutic tool can be traced to the contemporary movement towards cognitive science with an emphasis on embodied cognition. This has effectively elided a consideration of how the body itself, separate and apart from cognition, could be a source of intelligibility, inventiveness, and creativity. We argue for the need to broaden the therapeutic model of dance to more fully support embodied and creative self-expression by persons living with dementia. To achieve this, we explore how a relational model of citizenship that recognizes corporeality and relationality as fundamental to human existence brings a new and critical dimension to understanding the importance of dance in the context of dementia. Drawing on this model, we articulate a new kind of ethic characterized by a pre-reflective intercorporeal sensibility that requires the mobilization of public structures and practices to cultivate a relational environment for individuals living with dementia that supports human flourishing.

Dementia Care Work in Singapore: Embodied Relations and Power Dynamics

Based on research at a dementia day-care center in Singapore, I discuss how embodied care relations proceed amidst cultural expectations on aging, dementia, and care work. Engaging with approaches that conceptualize "care" as either empathy or control, I argue that care between older people with dementia, their families, and care workers can be understood as a reiterative, dialogic process whereby care participants strive to keep pace with each other, however briefly, due to cognitive decline, care workers' own limitations, and particular family difficulties. Care vacillates between practices of control, surveillance, and recognition, and comprises dynamic rather than enduring power relations.

Participatory arts programs in residential dementia care: Playing with language differences

This article examines connections between language, identity, and cultural difference in the context of participatory arts in residential dementia care. Specifically, it looks at how language differences become instruments for the language play that characterizes the participatory arts programs, TimeSlips and the Alzheimer’s Poetry Project. These are two approaches that are predominantly spoken-word driven. Although people living with dementia experience cognitive decline that affects language, they are linguistic agents capable of participating in ongoing negotiation processes of connection, belonging, and in- and exclusion through language use. The analysis of two ethnographic vignettes, based on extensive fieldwork in the closed wards of two Dutch nursing homes, illustrates how TimeSlips and the Alzheimer’s Poetry Project support them in this agency. The theoretical framework of the analysis consists of literature on the linguistic agency of people living with dementia, the notions of the homo ludens (or man the player) and ludic language, as well as linguistic strategies of belonging in relation to place.

Precarity in late life: rethinking dementia as a 'frailed' old age

Approaches to ageing that are organised around productivity, success, and active late life have contributed to views of dementia as an unsuccessful, failed or 'frailed' old age. Operating through dominant frameworks, socio-cultural constructs and organisational practices, the 'frailties' of the body and mind are often used to mark the boundaries of health and illness in late life, and shape responses accordingly. Our concern is that both the taken for granted and the 'imagined' can further marginalise persons who occupy the locations of dementia and disablement. This article analyses the extent to which frailty and dementia are better understood in the context of new forms of insecurity affecting the life course. Drawing on the concept of 'precarity', this article shifts debates on the 'fourth age' away from age or stage-based thinking, into a recognition of the shared vulnerability and responsibilities for care. The argument of this article is that 'precarity' represents a 'new form of ageing', notably as regards its impact on the upper extremes of the life course. The article concludes with a call for a response that is grounded in an acknowledgement of the fragility and limitations which affect human lives, this requiring grounding in inclusive forms of citizenship.

Dichotomising dementia: is there another way?

This article discusses the reduction of the complex experience of dementia to a dichotomised 'tragedy' or 'living well' discourse in contemporary Western society. We explore both discourses, placing them in the context of a successful ageing paradigm, highlighting the complex nature of dementia and the risks associated with the emergence of these arguably competing discourses. Specifically, we explore this dichotomy in the context of societal understandings and responses to dementia. We argue for an acceptance of the fluid nature of the dementia experience, and the importance of an understanding that recognises the multiple realities of dementia necessary for social inclusion to occur. Such an acceptance requires that, rather than defend one position over another, the current discourse on dementia is challenged and problematised so that a more nuanced understanding of dementia may emerge; one that fully accepts the paradoxical nature of this complex condition.

Insights Into Care Providers’ Understandings of Life Story Work With Persons With Dementia: Findings From a Qualitative Study

Background and Purpose: In Germany, life story work, an approach which acknowledges humans as narrative beings and honors biographies, is required by health authorities to be integrated in care provided in nursing homes. Insufficient attention to life story work could place residents at risk of dehumanization, particularly residents with dementia, who depend on support of others to tell and make meaning of their life experiences. Methods: We conducted a qualitative study to gain insights into care providers’ perceptions and practices of life story work with persons with dementia. Thirty-six care providers in 7 nursing homes participated in semistructured interviews or group discussions. We derived subjective theories (individual understandings) of care providers and higher-order concept patterns following the principles and processes of grounded theory. Results: We found a great variation in participants’ understandings of life story work. Some participants were unsure if and how life story work impacts persons with dementia. Starting points for improving the integration of life story work into practice are discussed. Implications for Practice: We conclude that care providers need a better understanding of life story work as a nursing intervention. The importance of the notion of humans as narrative beings and the multiple ways in which we story our lives as well as embody life stories needs to be further developed. Knowledge is required about the practical and systemic challenges of integrating life story work in the care of persons with dementia.

Geographical thinking in nursing inquiry, part two: performance, possibility, and non-representational theory

Part one in this two paper series reviewed the nature of geographical thinking in nursing research thus far. The current paper builds on it by looking forwards and providing a particular vision for future research. It argues that it is time to once again look to the parent discipline of human geography for inspiration, specifically to its turn towards non-representational theory, involving an emphasis on life that onflows prior to meaning, significance, and full cognition; on life's 'taking-place'. The paper introduces this way of viewing and animating the world. Some potential connections to nursing research and practice are suggested, as are some specific avenues for future inquiry. Explained is how, through non-representational theory, nursing might be re-imagined as something that reveals space-time.

Touch and relate: body experience among staff in habilitation services

In habilitation centres staff meet children with different impairments, children who need extensive support and training while growing up. A prevailing biomedical view of the body in habilitation services is gradually becoming supplemented by a perspective on the body as constantly involved in experiencing and communicating, the latter involving also the bodies of the therapists. Investigating body experience in habilitation staff in their encounters with the children may provide concepts that make it easier to reflect on what is going on in the interaction. When shared among larger number of peers and supported by further research in the field, reflected body experience may become a substantial aspect of professional self-knowledge. Our aim with this study was to contribute to the understanding of what it means to be a body for other bodies in the specific relational context of child habilitation, and more specifically to investigate what role the therapists’ body experience may play for professional awareness and practice. In the study, five physiotherapists and three special-education teachers spoke of physical and emotional closeness (the body as affection) but also of a provoking closeness (the body as provoked) with the children and of how their own body experience made them more attentive to the children's experience (the body as reference). Situations that included bodily limitations (the body as restriction) were described, as were situations where the body came into focus through the gazes of others or one's own (the body as observed). The body was described as a flexible tool (the body as tool), and hands were given an exclusive position as a body part that was constantly communicating. Three shifts of intentionality that form a comprehensive structure for this body experience were discerned. When professional reflection is evoked it may further body awareness, deepen reflection in practice and strengthen intercorporeality.

Grief, Anger, and Relationality: The Impact of a Research-Based Theater Intervention on Emotion Work Practices in Brain Injury Rehabilitation

BACKGROUND

Therapeutic emotion work is performed by health care providers as they manage their own feelings as well as those of colleagues and patients as part of efforts to improve the physical and psychosocial health outcomes of patients. It has yet to be examined within the context of traumatic brain injury rehabilitation.

OBJECTIVE

To evaluate the impact of a research-based theater intervention on emotion work practices of neurorehabilitation staff.

RESEARCH DESIGN

Data were collected at baseline and at 3 and 12 months postintervention in the inpatient neurorehabilitation units of two rehabilitation hospitals in central urban Canada.

SUBJECTS

Participants (N = 33) were recruited from nursing, psychology, allied health, recreational therapy, and chaplaincy.

MEASURES

Naturalistic observations (N = 204.5 hr) of a range of structured and unstructured activities in public and private areas, and semistructured interviews (N = 87) were conducted.

RESULTS

Preintervention analysis indicated emotion work practices were characterized by stringent self-management of empathy, suppression of client grief, adeptness with client anger, and discomfort with reactions of family and spouses. Postintervention analysis indicated significant staff changes in a relationality orientation, specifically improvements in outreach to homosexual and heterosexual family care partners, and support for sexual orientation and intimacy expression. No improvements were demonstrated in grief support.

CONCLUSION

Emotion work has yet to be the focus of initiatives to improve neurorehabilitative care. Our findings suggest the dramatic arts are well positioned to improve therapeutic emotion work and effect cultures of best practice. Recommendations are made for interprofessional educational initiatives to improve responses to client grief and potential intimate partner violence.

Care networking: a study of technical mediations in a home telecare service

This article examines the processes of technical mediation within familial care networks based on a study of home telecare targeted at older people. Supported by contributions from the actor-network theory as part of the social psychology of science and technology, these processes of technical mediation are analyzed using a qualitative approach. The data were gathered through six focus groups and four in-depth interviews; the participants in the study included users, relatives and formal carers. Thematic analysis techniques encompassing the information were used, revealing the effects on the patterns of caring relationships. The results show the interplay between presence-absence made possible by the devices; the two-way direction of care between the older people and the artifacts; and the process of sustaining care using the technology. We conclude that care should be seen as a socio-technical network where technology plays an active role in sustaining family relationships.

Embodiment and dementia: exploring critical narratives of selfhood, surveillance, and dementia care

In the last decade there has been a notable increase in efforts to expand understandings of dementia by incorporating the body and theorizing its interrelationship with the larger social order. This emerging subfield of dementia studies puts the body and embodied practices at the center of explorations of how dementia is represented and/or experienced. This shift towards a greater recognition of the way that humans are embodied has expanded the horizon of dementia studies, providing the intellectual and narrative resources to examine experiences of dementia, and their interconnections with history, culture, power, and discourse. Our aim in this paper is to critically explore and review dimensions of this expanding research and literature, specifically in relation to three key narratives: (1) rethinking selfhood: exploring embodied dimensions; (2) surveillance, discipline, and the body in dementia and dementia care; and (3) embodied innovations in dementia care practice. We argue that this literature collectively destabilizes dementia as a taken-for-granted category and has generated critical texts on the interrelationship between the body and social and political processes in the production and expression of dementia.

Dementia, personhood and embodiment: What can we learn from the medieval history of memory?

Memory and dementia are historical ideas that preceded the development of modern neuroscientific, psychogeriatric and medical approaches to aging and cognitive impairment. This article explores the value of such historical ideas in order to understand the discourses and metaphors by which Western thought has individualized memory as the guarantor of rational personhood, while at the same, treating memory decline as a threat to healthy and successful aging. Discussion focuses on the relationship between memory and the body in the classical and medieval ars memoria (the art of memory) and in the early modern philosophies of personhood, particularly the work of John Locke. Conclusions consider the significance of Western culture’s history of embodied memory as it moved from cosmic to individual to neurocognitive sites for our wider views about the treatment of dementia.

Demonstration of the usefulness of a theoretical framework for humanising care with reference to a residential aged care service in Australia

AIMS AND OBJECTIVES

To demonstrate the usefulness of a theoretical framework for humanising care of dementia patients.

BACKGROUND

The term humanisation of care has been increasingly used to describe an approach to health care that is informed by core dimensions of what it means to be human. Recent developments in dementia care highlight the importance of maintaining personhood in people with dementia.

DESIGN

A conceptual framework is proposed by which the humanisation of care can be understood and applied. Eight dimensions that articulate core features of what needs to be attended to in order for a person to feel more deeply 'met' as a human being are discussed. Evidence from an evaluative study of a dementia outreach service is used to illustrate the usefulness of the humanising framework.

METHODS

Case study examples demonstrate the value of this framework by describing how a dementia outreach service enables care staff in residential aged care facilities to change their focus in the provision of care to residents with dementia. Each of the eight dimensions of humanisation/dehumanisation is used to illustrate how the dementia outreach service team have led to the improvements in resident care.

RESULTS

Positive outcomes can be achieved by providing humanised care to residents with dementia.

CONCLUSION

The paper highlights the potential for the humanising framework to be used in dementia care and shows how the framework can be helpfully translated into practice so that carers are supported to adopt an inclusive view of care delivery.

RELEVANCE TO CLINICAL PRACTICE

A comprehensive framework, grounded in a strong philosophical foundation, can name a breadth of criteria for humanly sensitive care and can be translated into practice in such a way as to potentially transform the provision of care to residents in residential aged care facilities.

Re-spacing and re-placing gerontology: relationality and affect

This paper describes how space and place have been understood in gerontology as phenomenon that are both physical and social in character, yet are relatively bounded and static. The argument is posed as to how, following recent developments in human geography, a relational approach might be adopted. Involving a twist in current thinking, this would instead understand space and place each as highly permeable, fluid and networked at multiple scales. Moreover, it is proposed that the concept of ‘affect’ might also be insightful, recognising space and place as being relationally configured and performed, possessing a somatically registered energy, intensity and momentum that precedes deep cognition. Three vignettes illustrate the relationalities and affects in the lives and circumstances of older people, and how focusing more explicitly on them would allow for a richer understanding of where and how they live their lives. The paper closes with some thoughts on future theoretical, methodological and disciplinary considerations.

Applying Bourdieu's theory to accounts of living with multimorbidity

OBJECTIVES

Chronic illness is well researched. Broadly, empirical enquiry has focused on either determinants of behaviors or exploring lived experiences. This paper attempts to advance understandings of the lived experience of multimorbidity in broader cultural and structural settings.

METHODS

Twenty-three people in their early 50s were recruited from a community health survey in Scotland. The participants had 4 or more chronic illnesses and were interviewed twice. Key concepts of Bourdieu were applied to the data set

RESULTS

The analysis presented here is organized around 4 sections: 1) Habitus, capitals and the ill body; 2) Relational positioning; 3) Illness and symbolic violence; 4) The GP as dispenser of capitals. Applying Bourdieu's theory to the accounts highlighted how broader cultural structures worked their way into personal illness narratives and illustrated how living with multimorbidity is a dialectic of structure and agency.

DISCUSSION

Interventions and support for those with multimorbidity need to take into account the tensions of opposing habitus underpinning medical encounters and the ongoing negotiation of structure and agency which is integral to living with chronic illness and underpins illness actions such as help-seeking and self-managing.

Phenomenological shifts for healthcare professionals after experiencing a research-based drama on living with dementia

AIM

The aim of this article is to report research findings describing phenomenological shifts, that is, changes in patterns of lived experience, for healthcare professionals who attended a performance of a research-based drama, called I'm Still Here.

BACKGROUND

The research drama, based on six studies, was created to help change the ways persons understand, think about and relate with persons living with dementia.

METHODS

In 2006-2007, 50 healthcare professionals from various disciplines and eight nursing students participated in this study. Participants were recruited from four Canadian cities in the province of Ontario where focus groups were held before and after engaging in a live performance of I'm Still Here.

FINDINGS

Analysis of focus group transcripts showed shifts in patterns of lived experience for the healthcare professional participants as evident in the participants' descriptions. The phenomenological shifts reflected a move from descriptions of 'diminishing humanness to discerning humanness', from 'disengaged care/mundane relating to reflexive relating in the now', and 'terrifying portrayals of loss to awakening to hopeful possibility'. The shifts described herein are supported with examples from the focus group transcripts.

CONCLUSIONS

Findings reveal the power of drama as a vibrant and meaningful means of shifting understandings, images and intended actions of healthcare professions which have the potential to affect the lived experiences, relationships and quality of life of persons with dementia.

Rethinking sociability in long-term care: An embodied dimension of selfhood

Sociability, interaction through which solitariness becomes togetherness or a union with others, has largely been explored without reference to the importance of bodily sources of agency. Encapsulated in the theoretical notion of embodied selfhood is the pre-reflective nature of selfhood deriving from the body's pre-reflective capacity for engaging with the world and the socio-cultural significance of the body. This paper argues for an expansion of the discourse on sociability in dementia to include embodied selfhood as a source of interactive practices. An 8-month ethnographic study of selfhood in dementia was conducted in a Canadian long-term care facility. The findings suggest that social and cultural habits, movements and other physical cues serve important communicative functions in the course of social interaction. This underscores how sociability is an embodied dimension of selfhood, which not only broadens the discourse on sociability in dementia but also offers important insights to inform person-centred dementia care.

"Learning about your residents": how assisted living residence medication aides decide to administer pro re nata medications to persons with dementia

PURPOSE

This study identified how unlicensed staff members decide to administer medications prescribed pro re nata (PRN) to residents of assisted living (AL) settings designated for persons with dementia. Theories of knowledge, including explicit and implicit knowledge, discretion, and judgment, guided the analysis.

DESIGN AND METHODS

Data were collected and analyzed using qualitative methods. The staff members responsible for medication administration were shadowed for 6 consecutive days in three Oregon ALs. In-person interviews were conducted with 16 staff members, and residents' medication records were reviewed.

RESULTS

Medication aides' decisions to administer PRN medications were informed by resident request, interpretation of resident-specific actions, training and experience, and setting-specific practices. The theme, learning about your residents, was consistent across settings.

IMPLICATIONS

By administering PRN medications, medication aides play an important role in the daily care and comfort of AL residents with dementia. Policy makers need information about whether to permit unlicensed staff to administer medications and the level of training to require. This research suggests that training should recognize the tacit knowledge of practicing medication aides. Despite the role that PRN medications can play in the daily comfort and well-being of AL residents, little is known about as-needed medications prescribed versus those actually used across settings; also needed is an understanding of how other health professionals are involved in treatment plans that include medications.

Tacit and transitionary: an exploration of patients' and primary care health professionals' goals in relation to asthma

Goal setting is recommended in UK health policy to make health care more patient-centred, to enhance the likelihood of behaviour change and to improve health outcomes. Patient-centred care is thought to be particularly important in the management of long term conditions such as asthma. We therefore explored and compared the asthma goals of both health professionals and people with asthma within the primary care clinical consultation, and identified the potential barriers to achieving shared goals and more patient-centred care provision. We conducted a qualitative study based on semi-structured interviews with 15 people with asthma, 7 general practitioners and 6 primary care asthma nurses from Tayside, UK. The data were analysed using the 'Framework' methodology. Four potential barriers to the identification of goals were located. The first stemmed from the status and nature of patients' goals, while the remaining three related to the beliefs and practices of health professionals. These findings are discussed in relation to relevant sociological literature around the potential tensions between lay and professional knowledge, and also tensions in the relationship between knowledge and values. We conclude that barriers need to be recognised and addressed where possible before the achievement of shared asthma goals can become common practice. In particular, health professionals may require training in how to elicit goals with patients and how to differentiate between end states and goals that are in fact assumed to mediate the achievement of such desired end states.

Dementia care at the intersection of regulation and reflexivity: a critical realist perspective

OBJECTIVES

To understand point-of-care decisions, and in particular rule breaking, by personal support workers (PSWs) regarding institutionalized elders with dementia within a context of legislative and organizational care mandates.

METHODS

Qualitative baseline data including focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) were collected during a 2-year, multi-method trial of a 12-week interprofessional arts-informed educational intervention in two Alzheimer support units and were analyzed using a critical realist approach.

RESULTS

PSW care decisions were the outcome of a discordant interrelationship between PSWs' reflective deliberations, and legislative and organizational care mandates. PSWs responded to discordance through rule breaking in order to provide individualized care. Unbeknownst to PSWs, rule breaking was contingent upon supervisors' case-by-case complicity as they strove to balance fears of regulatory citations with private assessment of the soundness of PSW logic.

DISCUSSION

Quality care emerges at the intersection of policies governing long-term care, PSW rule breaking, and the supportive but undisclosed role supervisors play in these violations. Understanding this complexity has important implications for initiatives to improve care practices and to challenge legislation and policies that impede dementia care.

Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS

PURPOSE

The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process.

DESIGN AND METHODS

This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada.

RESULTS

PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care.

IMPLICATIONS

Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents' preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs' nascent occupational identity and their role as interprofessional brokers in long-term care.