This exploratory study has two major aims. The first is to investigate heuristically the sources and nature of meaning experienced by residents and staff living and working in an Australian nursing home. The second is to interpret those experiences within the context of wellness.The study utilises heuristic inquiry as the research method from an occupational science perspective. Occupational science is concerned with the ways in which humans realise their sense of meaning through both their daily occupations and their unique way of being in the world.Heuristic inquiry is utilised for both the research design and the analysis of data. The primary source of data was my own experience of working in Australian nursing homes as a nurse, educator, and grief counsellor; and of having supported the six members of my family who have lived and died in Australian nursing homes. In addition multiple other sources of data were accessed: residents and staff from three suburban Australian nursing homes; personal and professional memoirs of life and work in Australian nursing homes; novels depicting characters faced with nursing home life; and research report on the needs of elderly Aboriginal people also faced with nursing home admission.Data were collected using a diverse range of techniques: self dialogue, participant-observation, informal, semi-structured, and group interviews, analysis of staff journal entries, and analysis of the textual material - memoirs, novels, and the research report.The findings indicate that nursing home residents experience a sense of meaning when they are able to maintain a sense of connection with an enduring sense of self. Nursing home staff, on the other hand, experience a sense of meaning in association with their work when they are able to access their personally constructed vision of a professional self identity. Living and working with a sense ++ / of wellness, whilst possible, tends not to be an everyday experience for either residents or staff.This study makes an important contribution to the understanding of the interior experiences of both nursing home residents and staff. It explores the notion of wellness within the nursing home context and puts forward suggestions for promoting wellness in the nursing home. The study also makes a significant contribution to the discipline of occupational science and the application of heuristic inquiry to social research.

Changes in demographic patterns and the burden of chronic illness have challenged palliative care clinicians to engage populations other than those with malignant disease. This new paradigm has promoted the development of a population based approach to service delivery which aims to extend the reach of palliative care to hard to reach populations, including older people in residential aged care. In Australia, the high levels of disability and death experienced by older people in this care setting has resulted in policy promoting the delivery of a palliative approach to care. Achieving health care reform in this complex health care environment has traditionally been difficult to realise due to a range of workforce, training, funding, variable organizational philosophies and legal factors. The “Residential - Palliative Approach Competency” (R-PAC) Project aimed to collaboratively develop, implement and evaluate a sustainable model of care to facilitate the delivery of a palliative approach to care for older people admitted to residential aged care facilities, in regional Australian. Action research, with a focus on improving care and involving participants, was used to promote the delivery of a palliative approach in residential aged care facilities. The R-PAC Project was designed to follow the action research sequence of reflection, assessment, planning, action and observation. Nested within the action research method are eight distinct but interrelated studies in a mixed method design. Study A, a focused needs assessment undertaken as part of the preliminary investigations, confirms that older people in aged care have unmet palliative care needs. The three studies conducted during Phase One provide a greater understanding of delivering palliative care in the residential aged care setting. Study B, a chart audit identified the strengths and gaps in end-of-life care provision in the local aged care setting. While, Study C identified that aged care nurses and care assistants are committed and compassionate about delivering palliative care but desired greater palliative care competencies. The palliative care attitudes, values and learning needs of aged care providers were explored in greater depth in Study D. The data from these investigations guided the development and implementation of a multifaceted intervention during Phase Two. Following the implementation of the multi-faceted intervention and during Phase Three another series of investigations was undertaken to measure the impact of the collaborative intervention. Focus groups were used to determine the perceptions of aged care providers toward the multi-faceted intervention (Study E) and to seek the views of general practitioners (Study F). These data revealed that aged care nurses and general practitioners wanted to establish a more collaborative approach to care planning and delivery. The survey (Study G) and chart audits (Study H) were repeated in Phase Four in order to measure the impact of the action. The findings of the survey of aged care nurses and care assistants shown an increase in palliative care competencies, while the chart audit demonstrated positive trends in improving end-of-life care. Although, some aspects of care, particularly advance care planning and routine use of pain assessment tools required ongoing attention. This data propel the R-PAC Project into Phase Five and the development of a model of care to promote the delivery of a palliative approach, which was informed by the research findings. The R-PAC Project use of the action research method has facilitated a cascade of engagement and participation of all residential aged care facilities in this regional community and enabled practice innovation. The project has seen the sharing of valuable insights into usual practice and collaboratively engaging aged care nurses, care assistants and general practitioners in developing practical solutions to end-of-life care. This process has allowed for the acknowledgement and validation of the role of aged care providers, fostered personal empowerment and identified the importance of collaboration. This research has provided greater insight into the palliative care needs of people in residential aged care and collaboratively developed an intervention to improve the outcomes of older people. Study findings have also identified important issues requiring ongoing evaluation, particularly multidisciplinary team meetings and care planning. / Doctor of philosophy (PhD)

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)

<p>Syftet med denna studie var att beskriva hur vårdare inom äldrevården upplever sin arbetssituation. Metoden som använts var en beskrivande litteraturstudie. Data samlades in via databaserna Medline via Pubmed och Cinahl. Sökorden nursing homes, elderly care och geriatric care kombinerades med experience och personnel för att ett så stort område som möjligt av äldrevården skulle ingå i sökningen. Sökordet Scandinavia valdes för att författarna ville fokusera studien på skandinavisk äldrevård. Resultatet visade att vårdarna ansåg tidsbristen vara det som påverkade den goda omvårdnaden negativt, det vill säga att det inte fanns tid att ge den omvårdnad som var önskvärd. Vårdtagarnas anhöriga sågs som en tillgång för de äldres välmående men att de ibland upplevdes som krävande och tålamodsprövande. En dåligt fungerande organisation samt ett dåligt ledarskap var orsak till att de inte kunde se till att de äldres behov av omvårdnad uppfylldes. Den goda kamratskapen och lagandan inom arbetsgruppen var viktig för att kunna ge god vård till de äldre. Positivt ansågs också utbildning och handledning för att kunna reflektera över sitt arbete och göra prioriteringar i arbetet. Arbetstillfredsställelse fick vårdarna genom den glädje som uppstod genom den ömsesidiga närheten mellan vårdare och de äldre. Då vårdarnas arbetsinsatser bekräftades uppstod positiva känslor.</p> / <p>The aim of this study was to describe how carers in the elderly care experience their work situation. The method used was a study of literature with descriptive design. Data was collected via the databases Medline and Cinahl. The search words were nursing homes, elderly care and geriatric care in combination with experience and personnel, because the authors wanted a wide database search. The search word Scandinavia was used because the authors wanted to focus on the Scandinavian elderly care. The result shows that the carers thought it was the lack of time that affected the good care of the elderly. The elder's relatives were considers as a resource for the elder's wellbeing but sometimes as demanding and as trying the carers patience. The carers thought that a poor organisation and management were some of the reasons to why the elders' need of good care was not implemented. Good fellowship and team spirit in the working group were important for giving good care to the elderly. Education and supervision helped the carers to reflect and prioritise their work.  The carers felt work satisfaction through the mutual togetherness between them and the elderly. When the carers work efforts were confirmed positive feelings aroused.</p>

Syftet med denna studie var att beskriva hur vårdare inom äldrevården upplever sin arbetssituation. Metoden som använts var en beskrivande litteraturstudie. Data samlades in via databaserna Medline via Pubmed och Cinahl. Sökorden nursing homes, elderly care och geriatric care kombinerades med experience och personnel för att ett så stort område som möjligt av äldrevården skulle ingå i sökningen. Sökordet Scandinavia valdes för att författarna ville fokusera studien på skandinavisk äldrevård. Resultatet visade att vårdarna ansåg tidsbristen vara det som påverkade den goda omvårdnaden negativt, det vill säga att det inte fanns tid att ge den omvårdnad som var önskvärd. Vårdtagarnas anhöriga sågs som en tillgång för de äldres välmående men att de ibland upplevdes som krävande och tålamodsprövande. En dåligt fungerande organisation samt ett dåligt ledarskap var orsak till att de inte kunde se till att de äldres behov av omvårdnad uppfylldes. Den goda kamratskapen och lagandan inom arbetsgruppen var viktig för att kunna ge god vård till de äldre. Positivt ansågs också utbildning och handledning för att kunna reflektera över sitt arbete och göra prioriteringar i arbetet. Arbetstillfredsställelse fick vårdarna genom den glädje som uppstod genom den ömsesidiga närheten mellan vårdare och de äldre. Då vårdarnas arbetsinsatser bekräftades uppstod positiva känslor. / The aim of this study was to describe how carers in the elderly care experience their work situation. The method used was a study of literature with descriptive design. Data was collected via the databases Medline and Cinahl. The search words were nursing homes, elderly care and geriatric care in combination with experience and personnel, because the authors wanted a wide database search. The search word Scandinavia was used because the authors wanted to focus on the Scandinavian elderly care. The result shows that the carers thought it was the lack of time that affected the good care of the elderly. The elder's relatives were considers as a resource for the elder's wellbeing but sometimes as demanding and as trying the carers patience. The carers thought that a poor organisation and management were some of the reasons to why the elders' need of good care was not implemented. Good fellowship and team spirit in the working group were important for giving good care to the elderly. Education and supervision helped the carers to reflect and prioritise their work.  The carers felt work satisfaction through the mutual togetherness between them and the elderly. When the carers work efforts were confirmed positive feelings aroused.

Persons with dementia experience impairments in cognitive, behavioral, and functional ability, often leading to long-term care placement. The Enhancing Care Program was developed by the Alzheimer Society of Canada to assist organizations in improving care for this population. Although this program has been implemented in many facilities, the majority have been located in urban settings and there has been limited formal evaluation. Little is known about dementia care in rural facilities, or about how programs are implemented in rural settings. The Enhancing Care Program is based on eleven guidelines that outline best practices for caring for individuals with dementia. With the assistance of a facilitator from the Alzheimer Society, a multi-disciplinary team from the facility assesses their current ability to meet each guideline. In subsequent meetings, the team establishes specific, measurable goals to improve care in targeted areas. The two purposes of this study were to conduct a process evaluation of the Enhancing Care Program and to develop theory relating to the implementation of a program in two rural long-term care facilities. Observations were made over the course of seven months as teams worked through the guidelines and set goals. Focus group interviews consisting of team members took place at the end of the observation period. In addition, individual interviews were conducted with general staff, the facility managers, and the facilitator from the Alzheimer Society. Grounded theory methodology informed the research and analysis process. The theory that emerged, The Process of Building Effective Teams, explains the transition of the participants from collections of individuals to cohesive units that functioned as teams. Five key categories were developed in the theory: trust, respectful and open communication, transformational leadership, creating change collectively, and enhanced team culture. As part of the process evaluation of the Enhancing Care Program, 24 recommendations were made for program improvements.

Families who are dissatisfied with the nursing home care of their family member may supplement their care by hiring a private companion. Families who have the financial resources pay for extra care, while families who cannot afford a private companion receive the current standard of care. Anecdotal evidence suggests that private companion use has increased over time. However, there is no research that examines private companions. The goal of this mixed methods study was to provide empirical evidence about who private companions are, what they do, and why they are needed. Andersen and Newman’s Health Service Utilization Model was used to understand private companion use. This study used both survey research and grounded theory. A mailed survey was completed by 280 of 432 family members of nursing home residents in a Toronto nursing home, yielding a response rate of 65 percent. Grounded theory principles were used to conduct interviews with 10 family members to understand why private companions were hired. Almost two-thirds of nursing home residents had a private companion. Family members reported that they paid about $475 per week for private companions who provided about 40 hours of care per week. Private companions were mostly women and immigrants. Private companions performed many activities including assisting with activities of daily living, toileting, feeding, escorting to activities, and providing social support. In the survey, family members reported hiring a private companion for reasons related to families’ needs (e.g. quality of care concerns), residents’ needs (e.g. deteriorating health); and staff recommendations. The family members reiterated these reasons in the interviews. Quality of care was the overarching theme that captured the reason for private companion use, which encompassed the following themes: inadequate staffing, unmet residents’ needs, overburdened family members, and suboptimal nursing home environment. The qualitative data emphasized the importance of building relationships with nursing home residents. The predictors of private companion use in the multivariate analysis were longer duration of nursing home stay, higher resident dependency, and family members’ concerns with quality of care. This research is among the first to study private companions, and has implications for research, policy, and practice.

Families who are dissatisfied with the nursing home care of their family member may supplement their care by hiring a private companion. Families who have the financial resources pay for extra care, while families who cannot afford a private companion receive the current standard of care. Anecdotal evidence suggests that private companion use has increased over time. However, there is no research that examines private companions. The goal of this mixed methods study was to provide empirical evidence about who private companions are, what they do, and why they are needed. Andersen and Newman’s Health Service Utilization Model was used to understand private companion use. This study used both survey research and grounded theory. A mailed survey was completed by 280 of 432 family members of nursing home residents in a Toronto nursing home, yielding a response rate of 65 percent. Grounded theory principles were used to conduct interviews with 10 family members to understand why private companions were hired. Almost two-thirds of nursing home residents had a private companion. Family members reported that they paid about $475 per week for private companions who provided about 40 hours of care per week. Private companions were mostly women and immigrants. Private companions performed many activities including assisting with activities of daily living, toileting, feeding, escorting to activities, and providing social support. In the survey, family members reported hiring a private companion for reasons related to families’ needs (e.g. quality of care concerns), residents’ needs (e.g. deteriorating health); and staff recommendations. The family members reiterated these reasons in the interviews. Quality of care was the overarching theme that captured the reason for private companion use, which encompassed the following themes: inadequate staffing, unmet residents’ needs, overburdened family members, and suboptimal nursing home environment. The qualitative data emphasized the importance of building relationships with nursing home residents. The predictors of private companion use in the multivariate analysis were longer duration of nursing home stay, higher resident dependency, and family members’ concerns with quality of care. This research is among the first to study private companions, and has implications for research, policy, and practice.

Persons with dementia experience impairments in cognitive, behavioral, and functional ability, often leading to long-term care placement. The Enhancing Care Program was developed by the Alzheimer Society of Canada to assist organizations in improving care for this population. Although this program has been implemented in many facilities, the majority have been located in urban settings and there has been limited formal evaluation. Little is known about dementia care in rural facilities, or about how programs are implemented in rural settings. The Enhancing Care Program is based on eleven guidelines that outline best practices for caring for individuals with dementia. With the assistance of a facilitator from the Alzheimer Society, a multi-disciplinary team from the facility assesses their current ability to meet each guideline. In subsequent meetings, the team establishes specific, measurable goals to improve care in targeted areas. The two purposes of this study were to conduct a process evaluation of the Enhancing Care Program and to develop theory relating to the implementation of a program in two rural long-term care facilities. Observations were made over the course of seven months as teams worked through the guidelines and set goals. Focus group interviews consisting of team members took place at the end of the observation period. In addition, individual interviews were conducted with general staff, the facility managers, and the facilitator from the Alzheimer Society. Grounded theory methodology informed the research and analysis process. The theory that emerged, The Process of Building Effective Teams, explains the transition of the participants from collections of individuals to cohesive units that functioned as teams. Five key categories were developed in the theory: trust, respectful and open communication, transformational leadership, creating change collectively, and enhanced team culture. As part of the process evaluation of the Enhancing Care Program, 24 recommendations were made for program improvements.

<p>Background: Each year, 2 million older Americans complete three to four week courses of post-acute care in nursing homes and return home; however, scant research describes services to protect older adults during their transitions from nursing homes to home. In hospital-based studies, transitional care interventions were associated with improved health outcomes for older adults, but these interventions added new staff positions, which are likely cost-prohibitive in nursing homes. Further, no prior study explored transitional care provided for vulnerable, post-acute care patients in nursing homes. Thus, this dissertation was designed to develop new understandings about transitional care provided by existing staff members in nursing homes. The study has two specific aims: (a) describe transitional care and outcomes for older adults who obtain post-acute care in nursing homes from the day of admission through discharge; (b) explore the influence of interactions, among selected older adult patients and their group of nursing home caregivers, on their ability to accomplish transitional care processes.</p><p>Method: Using data from a literature review and theoretical models, including Donabedian's Model of Healthcare Quality and Anderson's Local Interaction Model, a conceptual model of transitional care for post-acute care patients in nursing homes was constructed. The conceptual model was then used to guide exploration of the research aims with a longitudinal, multiple case study of transitional care in a nursing home. The unit of analysis was the patient care-team, defined as individual post-acute care patients, family caregivers, and 6 to 8 professional staff in each team (e.g., rehabilitation therapists, physicians, nurses and social workers). Three patient care-team members were purposively sampled for study. Moreover, longitudinal data were collected using repeated interviews and observations with patients, family caregivers, and staff; document and daily chart reviews; and surveys of patient preparedness for discharge. Manifest content analysis and thematic analysis (qualitative methods) were used to conduct within- and across-case analyses of trajectories of transitional care and to identify strengths, gaps and inconsistencies in care. </p><p>Results: Findings related to the first research aim include a description of transitional care in the study nursing home. Serious gaps and inconsistencies in transitional care exposed older, post-acute care patients to risks for complications in their transitions from the study nursing home to home: (a) systemic supports were not available to support nursing home staff who provided transitional care; further, nursing home staff and leadership were unaware that they provided transitional care; (b) care processes were not in place to prepare older adults and their caregivers to continue care at home; (c) care-team interactions often excluded family members; and (d) post-acute care patients left the nursing home without resources needed to support safe transitions in care, including transitional care plans, education to appropriately respond to acute changes in health, written materials to guide care at home, referrals for medical follow-up after discharge, and transfers of clinical information to primary care physicians. </p><p>Findings related to the second research aim include a description of local interaction strategies and the effectiveness of transitional care processes. When professional staff more consistently used local interaction strategies, specified in the model, care-team members exhibited greater capacity for connections, information exchange, and cognitive diversity. Further, when care-team interactions were of high quality and sufficient frequency, there were multiple indications of more effective transitional care, such as patient engagement in care, inclusion of patient priorities in care plans, and problem solving which included family members and diverse members of the patient care-team. Thus, local interaction strategies were essential staff behaviors needed to adapt care processes to the specific transitional care needs of individual patients.</p><p>Because transitional care is a grossly under-developed care process in nursing homes, these findings will likely have immediate implications for practice and research. Findings will provide nursing home administrators and staff with resources to develop and evaluate care in nursing homes; further, the findings will help to create targets for protocol and care process development to strengthen existing practice and address deficiencies. Findings will provide researchers with resources for studying transitional care in diverse samples of nursing homes, which should facilitate development of testable hypotheses for needed intervention studies. In addition, the local interaction strategies findings in the study may generalize to other settings of care, where interdependent staff work is required to establish connections, information networks, and to coordinate care among multiple staff members.</p> / Dissertation