Ethical decision-making is an integral aspect of gerontic nurses' experiences of caring for nursing home residents and their families. This thesis examines the author's journey into the life-worlds of nine registered nurses working in an Australian nursing home to explore how they manage the ethical problems they encounter in their everyday experience of nursing home life. As a result of interviews, the study revealed that nurses utilized an approach to ethical decision-making not previously described.This approach was identified as being professional, familial, collegial and reciprocal in nature. As an approach to ethical decision-making, respectful relationships is a potential tool for nurses coping with the ethical problems that are an every-day aspect of their professional lives in a nursing home. Respectful relationships can guide nurses' ethical decision-making as they strive to do the right thing / Doctor of Philosophy (PhD)

This thesis examines how rapid demographic, social and economic changes are impacting on traditional care for the urban aged in China and Japan as both experience world record rates of ageing caused by greater longevity and lower birth rates. The challenge for their governments is to foster active contribution by the healthy aged to society and protection for the frail aged. China lags behind Japan in special treatment for senior citizens. The manner in which these two countries handle the ageing of their populations could provide valuable lessons for Australia in the future.

The Residential Aged Care (RAC) industry is the fastest growing sector of the health care industry in Australia, particularly with the needs of people aging eighty five years and over consuming most health care services (Productivity Commission, 2006). This thesis examines the staffing efficiency challenge that is facing the RAC industry in Australia, from the facility managers' perspectives. Staffing efficiency is a crucial component in the success of this industry that is labour intensive, delivering complex services twenty-four hours per day and seven days per week. By achieving staffing efficiencies, facility managers would minimise labour cost expenditures; thus, ensuring sustainability and growth of their organisation in the long run. The literature reviewed revealed limited number of scholarly reviews about staffing efficiencies conducted in Australia. Nevertheless, it highlighted a number of available staffing approaches available overseas which could be of promising results if they were adopted to suit the Australian industry and its operational systems. This thesis explores the prospects of RAC facility managers adopting 'alternative' or 'new' staffing methods in their facilities as one solution for this staffing challenge. In this study, the researcher refers to alternative or new staffing methods as staffing methods that are not currently utilised in the staffing of RAC facilities in Australia. Using an Interpretivist research paradigm, 18 semi-structured interviews were conducted with the participating RAC managers in their work environment. During the interviews, a sample alternative staffing tool, developed prior to the study, was displayed. The data generated were analysed in the context of the RAC industry's environment, operational challenges, and through the theoretical implication of neo-liberalism. This theory provided a vehicle for the analysis of the data generated on staffing within the context of Australia's current economic policies. The generated data revealed little chance of such adoption reflected in a number of findings including: 1) Participants' lack of interest in adopting alternative staffing methods despite their comments on the unsuitability of current tools. 2) Overdependence of the industry on cost cutting measures and monetary performance indicators. 3) Lack of incentives for the adoption of change and 4) Lack of preparedness of RAC facility managers for such change. Thorough analysis of the findings revealed misinterpretation of free-market principles in the currently utilised staffing tools, which links demand of service to the number of individuals requiring care on one hand, and the supply of services available to the number of staff rostered to provide the care, on the other hand. The application of such a principle on the RAC industry is questionable, particularly with the inconsistency in the elderly residents' care needs and the staffing skill mix. A new staffing approach that uses the care required by the elderly individuals and the staffing skills available in the facilities as the basis for the demand and supply principles will provide a plausible solution for facing the staffing challenge. A joint venture between the Australian government and the RAC industry to encourage the adoption of such alternative staffing approach is the recommended way forward for improving staffing efficiencies.

Yes / Many intervention studies lack an investigation and description of the factors that are relevant to its success or failure, despite its relevance to inform future interventions. This study aimed to explore the facilitators and barriers to the implementation of a psycho‐educational intervention for care assistants caring for people with dementia in aged‐care facilities. A process evaluation was carried out alongside a pretest/post‐test controlled study conducted in aged‐care facilities. Seven focus‐group interviews involving 21 care assistants (female; mean age 43.37 ± 10.0) and individual semi‐structured interviews with two managers (female; mean age 45.5 ± 10.26) were conducted 2 weeks and 6 months after the intervention, in two aged‐care facilities. Interviews were recorded, transcribed and submitted to content analysis by two independent researchers. Results were organised into implementer, participant and organisation level hindered and facilitator factors. Findings enable the interpretation of the experimental results and underscore the importance of collecting the perception of different grades of staff to obtain information relevant to plan effective interventions. / Foundation for Science and Technology (FCT). Grant Number: SFRH/BD/72460/2010 and RIPD/CIF/109464/2009

Yes / This study assessed the effects of a psycho-educational intervention on direct care workers' person-centredness during morning care to residents with dementia. A controlled pretest–posttest study was conducted in four aged-care facilities with 56 direct care workers (female, mean age 44.72 ± 9.02). Two experimental facilities received a psycho-educational intervention comprising person-centred care competences and stress management skills; control facilities received an education-only intervention, without stress support. In total, 112 video-recorded morning care sessions were coded using the Global Behaviour Scale. Both groups reported significantly higher scores on eight of 11 items of the Global Behaviour Scale and on the Global Behaviour Scale total score at posttest (F=10.59; p=0.02). Global Behaviour Scale total score improvements were higher for the experimental group, with values close to significance (F=3.90; p=0.054). The findings suggest that a psycho-educational intervention may increase care workers' person-centredness. Further research is needed to explore the long-term sustainability and extent of its benefits on workers and residents. / Foundation for Science and Technology

Doctor of Philosophy / Aim and significance: The aim of this research was to explore the phenomenon of Australian nursing home care from the perspective of those who provide and receive it. Its focus is on the processes of ‘quality care’ provision and the meanings and evaluations that care providers attach to their work. In other words, its purpose was to shed light on the practices based on a conceptualisation of care that is entwined with the mechanisms of ‘care’ production and identity creation, or what actually happens in the daily life of the complex social phenomenon that is a nursing home. A related aim was to add to understandings of clinical nursing competence and develop tools that will assist nurses to conceptualise and implement positive change in this setting. Background: The provision of care to our elderly has become a major concern with the ageing of the world population. This is occurring in the context of decline in the capacity of families to take on the responsibility of elder care, and of increasing commercialisation of medical care. Governments have responded by shifting their responsibilities from direct care provision to become auditors of the business of care provision that is supported by public funding. However poor care delivery has largely been hidden from the public gaze. Governments present themselves as having systems in place, creating the illusion of rational control; in reality, like the market economy, there is a ‘black box’ of unknown factors driven by human impulse. The aim of this study was to open up the black box of ‘quality care’ to direct observation, drawing insights from the literature on organisational culture and with a focus on the frontline worker and the construct of quality assurance. Specific research objectives were to: • Document the beliefs and attitudes of care providers towards elderly people in general and the needs of nursing home residents in particular • Elicit the range of meanings and evaluations that care providers attach to their work • Describe their constructions of ‘care’ and ‘quality of care’ and the organisational factors they believe to impact (positively and negatively) on their ability to provide it. • Through in-depth understanding of a particular setting, generate grounded theoretical insights into the phenomenon of quality of residential care that are more widely applicable Method: The study adopted a paradigmatic bricoleur approach, seeking to develop connections between a diverse range of methodologies. These included combinative ethnography, phenomenology, hermeneutics and traditional grounded theory. Conceptual insights were drawn from organisational studies, psychosocial nursing and coping theory. The research site was an Australian for-profit suburban nursing home. The student investigator conducted more than 500 hours of participant observation, recording extensive field notes which were analysed through the perspective of a hermeneutic middle way horizon that directed an augmented constant comparison traditional grounded theory approach. Additional data were collected through formal indepth interviews with six key stakeholders. Interviews were tape recorded, transcribed in full and analysed to reveal themes that were brought within a hermeneutic circle that spiralled recursively from the whole to the part and back to the whole. Findings: Eight key interrelated factors in the production of care within the nursing home were identified: internal and external accountability (the accreditation system); economic considerations; management and training; advocacy; characteristic of residents; care providers’ working conditions and environmental stressors; organisational culture; and the work/care styles of individual care providers. I have categorised the latter into two main types: ‘tortoises’ and ‘hares’. This typology is then used to generate a process-driven schematic diagram that tracks a hypothetical novice care provider through the process of learning how to produce ‘care’. Specifically, I found that nursing home ‘care’ is the outcome of a complex social process involving the interplay between resident, relative, care provider, proprietor, quality assessors and government within the phenomenon of the nursing home. Such care, indeed the phenomenon of the nursing home itself, is not a stable, controllable entity but is in a constant state of flux – what I refer to as a moral ecology. In their everyday practice, care providers devise a construction of ‘quality care’ that is more clearly grounded in their own worldviews and the development of the own identity than in the formal quality assurance system of standards, guidelines and evaluations. Conclusion: Understanding the ‘black box’ of processes that produce care is the key to identifying courses of action that will improve care outcomes. The study findings also question the validity, assumptions and significance of the accreditation system, which only identifies some of the component variables, disregarding both the complexity within the ‘black box’ and failing to acknowledge that the quality of care outcomes is overwhelmingly dependent on individual care providers.

<p>The purpose of this study was to examine and describe how politicians and directors of care define and experience quality in aged care facilities. Further on we wanted to compare on which fundamental principles the participants base their opinion about quality and how they work with quality. To reach our aim we conducted five interviews with politicians and directors of care. The results show that it is hard to determine quality in an unambiguous and objective way. Quality in aged care appears to be about relations and encounters amongst people. The participants in our study agree that experiences are subjective and depending on individual expectations.</p><p>There are fundamental principles shared by both politicians and directors of care regarding safety and respect of human integrity. Directors of care point out the difficulties in having multiple perspectives to consider, residents and their relatives have other expectations on what services should be provided than the directors of care understand to be their assignment from the local government. It appears to be a gap between political goals and reality. The future will bring changes, regarding both needs and expectations. The participants see a challenge in developing aged care and meeting new generations of elderly.</p>

The purpose of this study was to examine and describe how politicians and directors of care define and experience quality in aged care facilities. Further on we wanted to compare on which fundamental principles the participants base their opinion about quality and how they work with quality. To reach our aim we conducted five interviews with politicians and directors of care. The results show that it is hard to determine quality in an unambiguous and objective way. Quality in aged care appears to be about relations and encounters amongst people. The participants in our study agree that experiences are subjective and depending on individual expectations. There are fundamental principles shared by both politicians and directors of care regarding safety and respect of human integrity. Directors of care point out the difficulties in having multiple perspectives to consider, residents and their relatives have other expectations on what services should be provided than the directors of care understand to be their assignment from the local government. It appears to be a gap between political goals and reality. The future will bring changes, regarding both needs and expectations. The participants see a challenge in developing aged care and meeting new generations of elderly.

This thesis contributes to the feminist economics' literature on caring labour with an empirical study of aged care nursing. This study critiques the positivist paradigm of neoclassical economics and argues that the Cartesian dualisms deeply embedded in both neoclassical economics and medicine result in an undervaluing of caring labour. Data was collected from nurses and managers working in residential aged care facilities in metropolitan Adelaide. Qualitative methods are utilised to uncover the role of nursing culture, underpinned by notions of gender, embedded in aged care nurses' work. This study explores how dualistic constructs such as love versus money and public versus private have become central to nursing work and impact on the way nurses' work is valued in residential aged care. The feminist economics' concept of provisioning provides a framework in which nurses' work can be valued. This framework is used to present a matrix to illustrate how nurses' work crosses these dualisms and uses a 'web of meaning' as a conceptual device to explain the inter-connectedness of nurses' work. The feminist economics' concept of provisioning is used as a means of overcoming the limitations that a dualistic world view has imposed on understanding the complexities of paid caring work. The empirical evidence presented in this thesis shows that aged care nurses do both nursing work and training in unpaid time and are vulnerable to exploitation. The remuneration they are paid is inadequate when the difficulty of the work they do and the level of responsibility they take is recognised. Their work contains a strongly non-commodified element, where the development of two-way relationships between nurses and the people they care for, their relatives and friends, other staff and the wider community are important. A key conclusion is that nurses focus on the intrinsic rewards of their work, which are undermined because aged care nursing is under-resourced. In particular, nurses do not have enough time to be caring which impacts negatively on their job satisfaction and the level of care they can provide.

The current literature suggests one of the challenges of nursing today is to meet the health care needs of the growing older population, people over the age of 65. Quality of nursing is important for acutely ill older people who are the largest group of patients in terms of hospital admissions. The ageing population is a major focus for social and economic planners and policy makers. There is an increasing need for health systems to change their focus to more closely assess strategies used to manage the acutely ill older hospital population. The main aim of this study was to improve the quality of nursing care for older, acutely ill, hospitalised medical patients. The study used a mixed method triangulated approach that utilised quantitative and qualitative methods to survey perceived needs of older patients, their family members/carers and the nursing staff, in the process of developing, implementing and evaluating a new model of care using a participatory action research (PAR) process. There were three specific objectives. The first was to evaluate which aspects of nursing care were considered most important for older patients during acute hospitalisation from the perspective of older patients, their family members/carers and their nurses. The second was to develop and implement a model of care that addressed the identified nursing care needs and priorities of older patients through the PAR process. The third was to determine whether employing a PAR process, the chosen model of care addressed the identified nursing care needs and priorities and resulted in increased patient satisfaction and improved health care for older patients. This study demonstrated the implementation of a PAR process to motivate nursing staff, utilising an evidence-based model of care approach, resulted in changes to clinical nursing practice that impacted positively on older patients’ and nursing staff’s satisfaction with care provided, patient knowledge and final health outcomes. It is recommended that the findings of this study be applied to develop guidelines for acutely hospitalised medical patients, particularly for issues relating to educational sessions to increase the patient’s functional activities and knowledge levels of their medication regimes prior to discharge. / Master of Health Science (Hons)