Background: Over the past two decades, the growing number of older people in the Lebanon, the advances in medical technology, and the changing family patterns of support have combined together to increase access to long-term care facilities for older people. Lebanon, like other developing countries, still needs to define the policies and programs that will reduce the burden of an ageing population on its society and economy. Moreover, there is a need to ensure the availability of health and social services for older people and to promote the older person‟s continuing participation in a socially and economically productive life in long-term care institutions. Whilst quality of life is a meaningful expression in the Lebanon, it remains a sophisticated and complex construct and it provokes considerable debate about its constituent parts. This study contributes to the debate by presenting a model of factors determining quality of life for older people residing in two Lebanese nursing homes. This grounded theory is built on the analysis of data collected in interviews with older residents, staff members and family carers with the aim of exploring the meaning of quality of life in the nursing home setting from different contexts.Aims and Objectives: The overall aim of this study is to explore the perceptions, perspectives and meaning of quality of life for a theoretical sample of older people living in Lebanese nursing homes, care staff and family carers and to produce an explanatory theoretical model of experience using the classic approach to generating grounded theory. The research objectives were to: identify factors that older people living in nursing homes believe constitute a meaningful and good quality of life; identify the role of the staff employed by nursing homes in helping to support quality of life; and identify the meaning that families attach to quality of life and how this is constructed. Results: Constant comparative analysis of data generated from the three groups of participants led to the emergence of three interrelated sub-core categories: “maintaining self” for older residents, “maintaining identity” for staff members, and “maintaining continuity” for family carers. Each of these sub-core categories consisted of either three or four properties/phases to explain the experience of the older resident, the staff member, and the family carer in their trajectory towards achieving and sustaining quality of life. Following a theoretical integration, the three sets of sub-core categories were conceptually connected through the linking scheme of “maintaining interrelationships”. Transcending the data, and by increasing theoretical sensitivity, the core category of “relating” emerged to explain the dynamics of quality of life. “Relating” was also found to have temporal dimensions that worked on sustaining, restoring, and creating interrelationships, processes that had the „fit and grab‟ necessary to shed new light on the meaning of quality of life for all participants. Conclusion: This study is one of the few that has explicitly explored quality of life in nursing homes from the perspectives of all the key actors. As such it has made an important contribution to the literature particularly in recognising the role of “relating” and “maintaining interrelationships” in enhancing quality of life in nursing homes in the Lebanon. The contribution of the substantive grounded theory emerging from this study is not solely restricted to helping interpret the everyday experience of quality of life, but also includes implications for policy and practice.

There is a lack of a conceptual framework as to how cognitive demand and attributional variables interact and influence staff beliefs in response to challenging behaviour. This study tests the applicability of Gilberts (1989) attributions framework for understanding how staff cognitive demand influences staff attributions of challenging behaviour in a residential setting within Weiner's (1986) model of attributional dimensions. The use of this model may also serve to support the applicability of Gilberts' (1989) model in Geriatric settings in the context of previous research findings. The basic notion that is outlined in the introduction highlights that when we attempt to perform several operations at once, then this often results in the failure of the least automatic (most effortful) operation. A rationale for cognitive demand attributions is based on the research that has suggested that people go through a two-stage process when making attributions (Gilbert, 1989, 1991). Firstly, people assume that a person's behaviour is something to do with their disposition (internal factors) before an attempt is made to explain their attributions externally, accordingly taking into account external situational factors. It may be argued that if a person is already pre-occupied, distracted and experiencing high levels of cognitive demand when making an attribution about another person's behaviour, they may not get to the second stage, as making such adjustments needs more concentration and effort than the first step which occurs spontaneously and quickly (Gilbert & Osbourne, 1989). Therefore, the implication is that staff experiencing high levels of cognitive demand would be more likely to make negative and blaming internal dispositional attributions of challenging behaviour. They are more likely to report higher levels of controllability for the behaviour and report that they feel less optimistic that the behaviour would change and that it affects wider areas of their life. The study employed a cross-over experimental design. Participants were asked to watch 2 video clips of challenging behaviour, one under conditions of cognitive demand (cognitive demand) and one under conditions of no extra demand (non-demand condition). A total of 46 staff working in nursing and residential homes for the elderly completed a self-reported attributions questionnaire developed for the purpose of the study, demographics questionnaire and stress measures. Results In general, the hypothesised model in the current study was found to be partially supported as results suggest that cognitive demand does have a role in determining staffs attributions of internality. There is evidence that more internal attributions are made under cognitive demand conditions for aggressive behaviour. No support however was found for "other" behavioural classifications. More weighting was given in the interpretations for aggression as the content of the videos was considered to be more matched in terms of behavioural typologies displayed in the video clips. Partial support was found for the role of cognitive demand on attributions of controllability. A significant relationship was found between cognitive condition and attributional dimension of controllability for "other" behavioural classifications. The results indicate that participants attribute higher levels of controllability whilst under cognitive demand conditions than whilst under non-demand conditions. However, no such support for a relationship between cognitive condition and attributional dimensions of controllability for ratings of aggression was found. The model was not found to be generalised to the other attributional dimensions identified within Weiner's model - no support was found for the role of cognitive demand on the other main attributional dimensions (Stability, Generability. and Globality) for either "aggression" or "other" behavioural classifications. No effect of stress was found. Conclusion The study set out to test the applicability of Gilbert's (1989) attributional framework for understanding how staff cognitive demand influences staff attributions of challenging behaviour in a residential care setting and with reference to Weiner's (1986) attributional dimensions. The hypothesised model in the current study was found to be supported, as results suggest that cognitive demand does have a primary role in determining staff attributions of internality and controllability. The model was not found to be generalised to the other attributional dimensions identified within Weiner's model apart from partial support for the influence on control. In conclusion cognitive demand was found to impair care staffs' ability to use contextual/situational information when forming causal attributions regarding an individual with dementia displaying challenging behaviour.

This study was an investigation of the phenomenon of dementia caregiving burden and breakdown in community caregiving situations. 109 carer subjects participated in the study, with 91 current carers - 17 via face-to-face interview and 74 via the internet, and 18 past carers - two via face-to-face interview and 16 via the internet, contributing their experiences of dementia caregiving. Two new carers' assessment tools were devised to meet more fully the requirements of the 'Carers (Recognition and Services) Act 1995' (DoH, 1995), namely the 'Dementia Caregiving Problems Questionnaire (DCPQ)' and 'Dementia Caregiving Burden Questionnaire (DCBQ)'. These new assessments were tested and demonstrated to be reliable, with Cronbach Alpha scores of 0.7029 and 0.8430 respectively, and are recommended for implementation in clinical practice. The key predictive risk factors for high caregiving burden in this study were perceived stress; omission of caregiving satisfactions; carer depression; perceived impact on quality of life; perceived helpfulness of community care services; behaviour problems - especially shouting, swearing and screaming, irritability and night disturbance; poor quality carer/dependant relationship; mood problems; perceived helpfulness of informal support; perceived impact of caregiving on dependant emotional well-being and, to a lesser extent, hours spent in caregiving. The key predictive risk factors for expected relinquishment of home caregiving were DCBQ score; perceived impact on quality of life; perceived stress; carer depression and, to a lesser extent, geographical distance in caregiving; perceived helpfulness of community care services and omission of positive feelings in the carer. Based on the above risk factors, a new 'Dementia Caregiving Breakdown Risk Assessment Tool (DCBRAT)' is proposed for use by community care managers to identify 'at risk' caregiving situations so that service interventions can be targetted more towards carers who are highly burdened in their role, who are at risk of developing psychological health problems or who may be nearing breakdown in their caregiving situation. Thus the effectiveness of service interventions may be maximised and optimal health gain for carers achieved, resulting in improved outcomes for people with dementia. The DCBRAT and the similarly proposed 'Conceptual Model of Dementia Caregiving, Burden and Breakdown' will need to be further tested in post-doctoral research.