Older people residing in nursing homes have complex needs requiring the input of nurses skilled in managing multi-morbidities and psychosocial issues. However, in England, nursing homes have proven to be unappealing work settings for potential staff, while nurses who do work in these settings are often afforded low status. Such contradictions pervade current understanding of the nature of work in nursing homes. To-date, few studies have investigated the views and experiences of nursing home nurses themselves regarding the contradictions that arise from role and status issues. This study explores English nursing home nurses’ views regarding status and role. The aims of the study were constructed as follows:  To explore the experiences and views of nursing home nurses working with older people regarding their status and role. -To generate an understanding of how and why these experiences and views occur. -To explore whether emerging insights regarding nursing home nursing can inform workforce development processes. The methodology utilised was hermeneutic phenomenology, based upon the philosophies of Gadamer and Iser. Thirteen nurses from seven nursing homes were each interviewed five times using an episodic interview technique. Data analysis methods were adapted from Van Manen’s hermeneutic phenomenological approach, and Iser’s literary reception theory methods. Four categories emerged from the data - nursing ‘residents’ rather than ‘patients’, business role, stigma, and isolation and exclusion. From these categories, three themes were ascertained - uncertainty about role identity, unpreparedness for the demands of the role, and low occupational status. Participants feel uncertain, unprepared and stigmatised because they are positioned at the intersection of health and social care – a location where health and social care funding issues cross, and healthcare and social care work overlaps. Understanding generated from this study can inform workforce development processes.

In recent years, there has been significant interest in the concept of wellbeing in the academic literature. Likewise, Government strategies are increasingly being aligned with the promotion of positive mental health, as opposed to merely the treatment of illness. Experiencing wellbeing in later life has, however, been labelled by some as a ‘paradox’, as the conditions of older age are assumed to be negative and thus at odds with those which sustain wellbeing. On the whole, the notion of wellbeing as applied to older adults has been defined by ‘experts’, and the small number of studies that have examined this from the perspective of older adults have often reduced this to the life domains which support or undermine quality of life. Therefore, in order to gain a richer understanding of this topic, the aim of this study was to further explore older adults’ perceptions and experience of wellbeing. In this qualitative study, a combination of narrative inquiry and photographic methods were used to elicit wellbeing stories from older adults. Thirteen participants aged 56 – 82 years took photographs of the factors they associated with their wellbeing, which they discussed in narrative interviews. Analysis of these data revealed that there were six ‘narrative types’ present in the stories told by participants; namely Continuity, Proactivity, Opportunity, Recovery, Acceptance and Disruption. These findings were considered in relation to the narrative elements of tone, plot, agency, temporality and pace. Comparisons were made between the six ‘narrative types’ and the ‘narrative of decline’ which is assumed to shape the stories told by older adults. It emerged that, on the whole, the narratives which were present in my study were positive in tone, had plots of stability or progression, displayed high levels of agency in the storytellers, were placed in the present and within a coherent life story, and revealed a busy pace of life. The ‘narrative of decline’ was found to have little influence over the stories which were told. In addition, it seemed that there may be a new ‘wellbeing’ narrative which is more pertinent to those in younger-old age. Thus my findings suggest that wellbeing can be experienced in later life and that the ‘narrative of decline’ should no longer be automatically cited as the one which shapes the stories older adults can tell about their lives.

UK care home residents are frail, dependent and multimorbid. General practitioners (GPs) provide their healthcare but there is evidence that existing provision fails to meet their needs. Comprehensive Geriatric Assessment (CGA) comprises comprehensive multidisciplinary assessment, goal setting and frequent review. This thesis considers a possible role for CGA in UK care homes through three research projects. The Care Home Literature Review (CHoLiR) was a systematic mapping review of randomized controlled trials (RCTs) in care homes. It found no evidence supporting CGA as a whole but described some CGA components supported by RCTs: advanced care planning; interventions to reduce prescribing; staff education around dementia and end-of-life; calcium/vitamin D and alendronate in preventing fractures and osteoporosis; vaccination/neuraminidase inhibitors in preventing influenza; functional incidental and bladder training for incontinence; and risperidone/olanzapine for agitation. The Care Home Outcome Study (CHOS) was a longitudinal cohort study recording dependency, cognition, behaviour, diagnoses, prescribing, nutrition and healthcare resource use in 227 residents across 11 care homes over six months. It reported high levels of dependency, cognitive impairment, malnutrition, multimorbidity and frequent behavioural disturbance. Polypharmacy and prescribing errors were common. Variability between homes and individuals was significant for most baseline and outcome measures. Staff Interviews in Care Homes (STICH) was a qualitative interview study of 32 staff working with care homes including: GPs; care home managers and nurses; NHS community nurses and specialist practitioners. It described care defined by discontinuity and lack-of-anticipation; driven by communication failure, inadequate training and expertise in frail older patients, and arbitrary boundaries between care homes and the NHS which interfered with care. Using the findings of these studies, the author proposes a model of care which is multidisciplinary, guided by comprehensive assessment, reinforced by frequent review and delivered by experts in the care of frail older patients: CGA has a role in UK care homes.

Background: Advance care planning (ACP) was originally designed to promote autonomy and is commonly conceptualised as informing treatment and decisions in the event of a person’s loss of capacity. In the UK, healthcare policy has emphasised the potential for ACP to significantly contribute to improvements in experiences of death and dying for patients and their significant others. Older people with progressive frailty are at high risk of mortality, loss of capacity and increasing dependency on carers and care services, yet uptake of ACP in this group is poor. Little is known about whether frail older people regard advance care planning as relevant or what perspectives they have on decision making for the future. Aim: To explore the expectations, experiences and understandings of frail older people and their significant others of planning for future care and to examine the implications of this for the practice of ACP. Methods: The study adopted an exploratory case study design using serial qualitative interviews and the responsive interview technique. Frail older people and their nominated carers were recruited from hospital wards in a large University Hospital NHS Trust prior to discharge. They took part in up to two interviews either in hospital or in their homes. Within and cross-case qualitative analysis was undertaken. Findings: Sixteen frail older people and eight significant others were recruited (Seventeen female, seven male, age range 70-96). The study found that frail older people experience profound uncertainty, associated with rapid changes to their physical and/or mental state and complex challenges in everyday life. Consequently, their attention is focused on day-to-day maintenance of quality of life, rather than on future care or advance decision making. Many had difficulty imagining a future; as dependency grew, so did reliance on care services to support their needs. What once would have been deemed an unacceptable way of living became routine. For many, the care system offers a lifeline without which they would not be able to exist at home. However, it also appeared to offer little individual flexibility, meaning that frail older people struggled to assert the control over day-to-day decisions and choices that others take for granted. This increasing dependency and reliance on care and care services has the potential to undermine the decision-making capacity of frail older people. For many, autonomous choice and decision making gave way to relationships, partnerships and negotiations that are commensurate with a more relational model of autonomy. Conclusion: The end-of-life orientation of current ACP policy and practice is at odds with the dynamic nature of frailty and does not correspond to individuals’ needs to maximise their current quality of life. The liberal ideal of autonomy as self-determination and self-interest presented by the legalistic and ideologically driven policy of ACP is out of step with the lived worlds of frail older people. For those facing increasing dependency on care and care services, frameworks that acknowledge a more relational approach when planning future care will be needed in order to engage this group of frail older people in ACP.

Increasingly, old people in India are moving into institutional settings. There is a paucity of qualitative research examining the condition of residents in care homes. This thesis addresses this gap through a detailed qualitative study of three such homes in Goa, India. It explores the care processes and practices in the care homes and how far they are attuned to the needs, lives and identities of their residents. An understanding of the experiences of residents as they have been undergoing different stages of entering and settling into a residential care setting has been the main focus of the research, which illuminates the context in which resident experiences were embedded. The thesis explores the process of institutional living: the conditions (losses and changes) that lead older people to enter institutional care; the losses and changes incurred while entering institutional care; the paradox between induced dependencies created by institutional control and structures resulting in passive compliance; and the struggles of the residents to resist these power structures. In documenting life for the resident in the care homes the thesis shows that their subtle daily forms of resistance exist within a framework of power. The final empirical chapter discusses how residents experience different forms of departure, whether as ending this struggle or beginning a new one. Data were collected through a combined ethnographic methodology of participant observation and semi-structured interviews with residents, staff and management over an eight-month period, in addition to a scoping survey of 37 care homes in the State. The study retrospectively examines residents’ experiences during various stages – pre-entry, entry, post-entry and exit – of their residential career, the drivers and constraints during these stages, and the role of staff and management in contributing to these experiences. These are presented as narratives – interleaved stories highlighting (some) important aspects of life in care homes in Goa. I have included the various responses made by residents to the different stages of their residential career – their ambivalences as well as their certainties, their anger as well as their passive acceptance, their dependence as well as their agency – and to interpret residents as sometimes vulnerable, sometimes invincible, and sometimes struggling. In doing so, I have provided insights into the ups and downs of life in care homes in Goa, through exploring paradigms that were crucial to residents’ lives in my study. These insights reveal that the dismantling of residents’ individual autonomy and control occurred prior to their coming into the institution. Once inside the care home, their lives were further altered by rules, routines and practices of staff and management. The resident’s identities thus were increasingly being defined by the institution. The findings further revealed that residents do not always accept passive dependency but instead struggle to carve their own identity within the institutional settings and controls they are subjected to. Finally, my findings reveal how perceptions and preparations for departure from the institution are coping mechanisms used by the residents and the staff alike, as extensions of their struggle for survival, freedom, and control. These findings lead to a greater understanding of how different processes are intertwined in residential careers for residents in care homes in Goa. The findings invite a rethinking of conceptions of autonomy and ageing, passive compliance and agency, and departure and coping, particularly within the context of institutional living in Goa. This study has thus illustrated the mechanisms in place for older people entering, settling and leaving care homes in Goa and demonstrated whether these mechanisms are adequately suited to their needs. The hope is that this understanding will contribute to the development of improved policy and practice that better reflects the needs and wellbeing of older people.

Set within the context that the world’s population is ageing at an unprecedented rate, it is argued that care of the elderly, and their everyday lived experiences are poised to become prominent concerns. In the shadow of this, the ageing population poses a myriad of challenges not only for the elderly but also for policy makers who put in place systems for the provision of services within residential care homes. By virtue, given that communities of elderly consumers voices are often muted within many academic analyses of social policy and service provision this study illuminates and distils communities of elderly consumers understandings of residential care homes. Given the absence of suitable literature within the fields of marketing and interpretive consumer research, this study turns to the sociological and anthropological literature of Hall and Jefferson (1976) and Levi-Strauss (1966). In doing so, communities of elderly consumers within residential care homes can be theorised as a cultural community of ‘bricoleurs’ within a ‘cultural map of meaning’. Furthermore, viewed through this lens, such bricoleurs can be seen to understand their meaningful everyday lived experiences within, and through, the use of ‘bricolage’. Emanating from eight existential-phenomenological interviews, a rich picture emerges wherein bricoleurs understandings of residential care homes can be seen to be embedded not only within, but also through, such things as the body, leisure trips, noise disturbances, death, large items of furniture, small hand-sized objects, mobility aids, quality of care and social interaction. Moreover, in the light of the resultant interpretations common themes can be seen to emerge within communities of bricoleurs social and material understandings of residential care homes, namely the notion of cultures of dependency, trauma and comfort. This research contributes to marketing knowledge in that it argues that communities of ‘elderly bricoleurs’ within residential care homes can be seen to be held together by unique understandings of cultures of dependency, trauma and comfort. Furthermore, it is also argued that elderly bricoleurs address themselves to a relatively limited amount of bricolage that enables them to keep alive actual, desired, imagined and fictional community ties. Furthermore, the reality and efficacy of cultural communities of elderly bricoleurs seems to depend on their ability to address ‘whatever is to hand’ (Levi-Strauss, 1966) in order to construct and understand their cultural maps of meaning within residential care homes.

As the population of people in the UK, over 65, increases and the welfare system moves from a collectivist, towards a consumerist system, involving older people in their rehabilitation and care becomes more important. It is recognised that the effectiveness of practices to increase involvement varies. The reasons for this include the lack of clarity about the meaning of involvement in health care. The aims of this research were to develop a substantive theory, which explains the meaning of involvement for older people in their rehabilitation after acute illness and facilitates recommendations for health care practice development. Grounded theory was employed to collect longitudinal data from four older people, their practitioners and support staff, during the participants’ rehabilitation stay of around six weeks in an Intermediate Care unit in the UK and at home. Data were collected using recorded, semi-structured interviews and conversations, from December 2008 to November 2009 and were analysed qualitatively. The findings suggest that involvement in rehabilitation operates through an Involvement Attribute set consisting of two interdependent groups of Involvement Attributes (the psychologically-based and the action-based). Collectively, the Involvement Attributes are: the possession of a Vision, Incentive and Goals, a positive Disposition; a propensity for Cognitive Development; Goal planning, setting and achievement; and Risk Management. To be maximally involved the Involvement Attribute set has to be strong, balanced and with alignment between the two groups. Involvement in rehabilitation is also related to the type of relationships developed with the health care staff and relatives. Improvements in Involvement Attribute sets require a move away from paternalistic relationships towards the collaborative, partnerships suggested within relationship-centred care. In this way, involvement of older people in rehabilitation is: “A joint commitment within therapeutic relationships to determine and be determined in the pursuit of an Involvement Attribute set that is strong, balanced and aligned”.

This grounded theory study explored the influences that surrounded decision making for people with a minimal requirement for care, who entered a care home with registered nurses (RN’s) when their needs could be met in an alternative environment. The study was undertaken in a geographical area in England, which has in excess of 3,500 care home beds staffed with RNs. In May 2011, there were reported to be 183 residents with minimal care needs, resident in a care home with RNs. The study utilized a grounded theory methodology as described by Glaser and Strauss with influences from Charmaz. The initial sampling was purposive progressing to theoretical. Interviews were conducted with twelve care home residents responsible for funding their own care home fees, assessed as not requiring care by RNs. Data analysis was in accordance with the principles of grounded theory and identified two main categories. The first category, entitled “choosing the path” focused on the decision making process which described a perceived paucity of help and support received by participants and their families in identifying and exploring the available options. The second category termed “settling in” related to the process of adaptation to the new environment. It appeared that participants with greater control over the decision making process found it easier to settle into the home, conversely those with the least control found it more difficult to adapt. These two categories linked to form the emerging theory of “crossing the bridge” from independent living to becoming a care home resident. It is important health and social care practitioners use appropriate evidence based knowledge when assisting older people and their families to consider available options. The findings of the study add to the body of evidence concerning the factors that influence people when considering their future care and the importance of informed decision-making.

Thirty years have passed and five major reforms have followed since the establishment of the Greek National Health System (NHS) in 1983 on universal coverage as an elementary policy goal, and the Greek NHS is still insufficient with regard to organisation, coverage, funding and delivering health services. The primary objective of the thesis is to employ quantitative empirical methods to explore some key aspects of equity in the receipt of health care in Greece among the older population via two nationwide and one urban setting datasets. This thesis comprises three essays which shed light on the equity issue before and after NHS major reforms of 2001-4 and 2005-7. The findings of this thesis suggest that inequalities in health care exist mainly for the probability of specialist and dentist private visits. Income- related inequalities are less apparent in probability of inpatient admissions and probability of outpatient visits, favoring the less advantaged. Income itself is not the only contributor. The findings indicate intra and interregional inequalities in most of health care services use except for probability of GP visits, favoring residents of thinly-populated areas. Compared to Athens region, regional disparities-inequalities are not apparent for inpatient care, as well. Furthermore, the findings suggest that even though we signify territorial disparities in the probability of specialist visit favoring the better off, once the positive contacts of specialist visits are included, the elderly have equal probability to make a specialist private visit, irrespective of their income and their region of residence. In addition, this thesis finds that inequalities are apparent among the Social health insurance funds (SHIFs) in use of most health care types, except the probability of inpatient admissions. Non Noble Farmers OGA SHIF - who tends to be less advantaged - has a more pronounced pro poor contribution to overall inequity in the probability of specialist private visit than the Noble SHIFs, revealing an unfair relationship. This thesis also finds that OOP expenses constitute a significant financial burden to inpatient and outpatient care. There is a regressive trend in OOP amount for inpatient admission in terms of ability to pay and region of residence favoring residents of thinly-populated areas and Central Greece region- who tend to be less advantaged. For outpatient care, there is a progressive trend in OOP amount in terms of ability to pay, SHIF coverage and region of residence. The thesis provides useful tools for understanding and measuring inequalities in the use of health care among the older population, who are the most constant consumers of health services. It urges policy makers to review the governance of primary health care by setting conditions and implements measures for improving efficiency, unifying SHIFunds, eliminating geographical inequalities and control the role of OOP expenses as significant barriers to access health care, especially during the current period of economic crisis.

Government policy has existed to protect adults who may be at risk of abuse since 1993 and was significantly revised in 2000 by ‘No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse’. However, a catalogue of abuse of older people in care homes subsequent to 2000 confirms that abusive acts continue. This thesis examined the extent of abuse in English care homes and has sought answers to the question of why it endures. The research employed a mixed methods approach. An anonymously completed questionnaire was used to quantify and explore any previous experiences of abuse from newly appointed care staff in five newly opened care homes. Concurrently, thirty-six semi-structured interviews were conducted with care home staff working in a sample of established homes in five local authority areas to explore their perceptions and experiences of abuse. A clear conclusion from the findings is that action is required at both societal and care home organisational levels to strengthen the prevention of abuse.