This study was an investigation of the complexities and challenges of change in a community-based aged care facility in Western Australia, to reveal the impact and influence of change on the community. It explored the impact of change on both the residents and the senior management team, as leaders of the organisation, and explored how change influenced the redevelopment process and future of the organisation. There is considerable literature on organisational change including the impact of change on the structure, function, process, workforce and leaders of the organisation. There is, however, little literature on organisational change within aged care communities, particularly with an emphasis on the complexities and challenges associated with change within an organisation that is both a business and a home for its residents. The study took the form of a participative action research study, occurring predominantly over two years (2002-2003) with some continuation into a third year (2004). The study had three phases and included two action research cycles and a critical reference group (CRG), comprising the senior management team (SMT) and researcher. It adopted a broadly qualitative methodology, using data from participatory observation and semi-structured interview; however, it did include quantitative and qualitative data from two 'quality of service' surveys for independent living residents and a staff satisfaction survey. The finding of this study are presented as a narrative account of the experiences of the participants. The study reveals that change associated with the redevelopment impacted on residents' wellbeing, described by them as quality of life. / The redevelopment process and associated change also emphasised the importance of communication and explanation with residents to understand elements of quality of life and to monitor and manage the impact of change. The findings of the study highlight the challenge faced by community-based aged care communities classified by government, the industry and the wider community as primarily not-for-profit, to balance financial accountability and social conscience. The perception of benevolence influenced the attitudes of residents and staff and made business accountability more difficult to explain and realise. The study reveals that change also impacted on the structure and function of the organisation as it built its capacity for change. It reshaped the relationship between the Board and senior management team (SMT), which was reported as an improvement in communication, work relations and leadership effectiveness. The development of the leadership team, being the senior management team, was influenced by change and the change process enabled this team to become a competent, confident, cohesive senior team, with a preferred leadership style. A further finding was the realisation of the value and appropriateness of the action research process. It provided tools and processes that were used to plan, act, analyse and reflect on the many aspects of organisational change and enabled the organisation, principally the SMT, to reflect on the impact and influence of change. The research process supported their development as leaders as well as the development of the team. The process of planning, collecting data, analysing data, reflection and action provided a structure and process that they continued to use in their management practices, as new situations continued to arise with the redevelopment process.

The need to address the issue of quality in aged care service provision in Australia has received increasing emphasis in recent decades. Particularly since the 1980s, the federal government has played a key role in ensuring that this is the case through the implementation of various reforms and regulatory strategies. In 1998, the national standards monitoring system which had been in place since the mid 1980s was replaced with a new system based on an accreditation model. In contrast to the former system which was wholly controlled by government and involved one-off inspections by government standards monitors, responsibility for managing the new system has been devolved to an independent body, the Aged Care Standards and Accreditation Agency. One of the Agency's primary functions is to assess compliance with the accreditation standards. A key component of the new system is its emphasis on continuous improvement which has been incorporated into the accreditation standards. As a consequence, the new system requires a much greater level of involvement and commitment by providers than previously. In order to continue receiving government funding all facilities had to be accredited by January 1st 2001. This study represents an evaluation of the accreditation system based on the views and experiences of service providers in Western Australia. It explored a number of issues relating to the basic philosophy and principles underlying the new system, the implementation process, the accreditation standards that are used as a basis for assessing service quality and the overall impact of the system on providers. It also sought providers' views about the strengths and limitations of the system and any areas in need of change or improvement. A descriptive design, using in-depth interviews as the method of data collection, was adopted for the study. / Participants from three levels of service provision, namely, facilities, organisations and peak bodies were selected on a stratified purposive basis. A total of 45 informants were interviewed. The findings indicated that, overall, as a regulatory approach the accreditation system was generally supported by providers and was regarded as having a number of positive features, particularly in comparison to the previous system. At the same time a number of concerns were identified. These related in particular to the assessment process, specifically the lack of consistency amongst assessors and the self assessment tool, and to the extent of information and guidance provided by the Agency. Concerns regarding the latter's role in relation to, and extent of independence from, the federal government were also identified. The study also found that the introduction of the system had impacted on providers in a variety of ways, both positive and negative, but particularly in terms of the demands on staff and financial resources. A number of 'broader' level factors, such as funding, nursing shortages and other often competing demands (e.g. assessing residents according to the Resident Classification Scale) were also felt to be impacting on providers' capacity to meet the requirements of the system. These concerns, along with concerns about the way in which the system would develop in the future, appear to have created a degree of uncertainty and in some cases apprehension amongst many providers. Although this study has focused on the experiences of Western Australian service providers, evidence from other reviews of the accreditation system where providers' views have been sought has indicated a widespread similarity in perceptions. This suggests, therefore, that there is a need for further review and refinement of certain aspects of the system as it moves into the second round.

This thesis explored the relationship between the discourses of nursing care, the nursing care provision, and the perceived nursing care needs of three highly dependent residents in a residential aged care facility in Australia. Residential aged care in this country has undergone major reforms since 1987 and the nursing profession has struggled with these changes because of the documentation, validation, and accreditation requirements; the inadequate determination of dependency on nursing care for funding; the Registered Nurse (RN) being removed from the bedside to a role of scribe and delegator; the increasing acuity and complexity of the residents' needs; an increase in the turnover of residents; a rise in the nursing staff attrition rate; the delivery of care by untrained and unqualified persons; the RN being accountable and responsible for the care given by 'non-nurses' from a distance; and, the inadequate skill mix and staff to resident ratios provided in these institutions. The interest of this thesis was to research gerontological nursing practice in the context of residential aged care. Residential Aged Care Facilities (RACFs) in Australia that care for the highly dependent elderly were identified in the thesis as disciplinary institutions that used 'subjectivation' as a means to control the efficiency and effectiveness of the labour force and the 'docile' bodies of the residents, whilst at the same time the government rhetoric is that of the quality of life standards and the rights of residents in these institutions. As well as the discourse analysis, an historical overview of the aged care reforms in Australia was undertaken for the period from 1975 to 2006 that demonstrated the effects the reforms have had on the voice of nurses and nursing care in these institutions. This analysis highlighted where nurses have been silenced and found the federal government determining what is nursing care and what is not nursing care, and also who is providing this nursing care. Using a case study approach and discourse analysis each of the three residents was studied using data from five sources namely the resident or relative, a RN, a careworker (CW), the current documentation pertaining to the resident's nursing care, and the non-participant observation of the nursing care provided. These discourses on the nursing care and perceived residents' nursing care needs were analysed using the theoretical base developed from the philosophy and research interest of Michel Foucault (1926-1984), who questioned the apparatus and institutions of Western cultures and searched for discontinuities in the practices of what he termed 'disciplines'. The results of the discourse analysis found nursing care practices that were alarming around the residents' perceived nursing care needs, the documentation of the nursing care provision, and the observed 'actual' nursing care provided. A questionable standard of nursing care was evidenced even though this facility had recently been accredited. A custodial level of mechanistic care was provided to residents in an extremely noisy and public environment within a culture of haste and bustle by unknowledgeable CWs, under the distant gaze of a RN, and the direction of the government documentation requirements. This resulted in unsafe, unethical, unprofessional, and negligent practices, as well as fraudulent, illegal, and dangerously out of date documentation practices. This was ultimately affecting each resident's quality of life, nursing care, and wellbeing and was an added burden on the residents' relatives. Many discontinuities, dissonances, conflicts, and contradictions in nursing practice were uncovered for these three highly dependent residents that may be transferable and similar to other highly dependent residents in this and other institutions. Indeed it may mirror other disciplines that provide care services, such as mental health care, acute care, and disability care provision. The concerns for the nursing profession have epistemological, ethical, and political ramifications for the residents and their relatives, the nurses, the non-nurses doing nursing work, the government, and the industry. Epistemologically new nursing 'knowledges' were being developed that were not resident focussed or based on evidence. Ethically, the legislated rights of residents were not being supported, despite the accreditation, funding, and complaint mechanisms in place - and this has the potential to have punitive ramifications for the industry. Professionally and politically, CWs were identified as non-nurses doing nursing work of a poor standard. This care was not based on accepted nursing practice, but developed through the documentation requirements of the federal government department, the applied constraints, and the CWs themselves. Furthermore, the documentation requirements were found to be a pretence in regard to funding through validation and accreditation, as well as a charade in nursing practice. There is presently a substantial third level of nurses who are identified legally and political as non-nurses doing non-nursing work (known as 'personal' care); but these non-nurses are doing nursing work and are identified by the nursing profession and the public as 'nurses' doing nursing work. These non-nurses who provided nursing care are not educated, licensed, or regulated, and are not accountable professionally to nurses or legally to the public. It is proposed that CWs are in need of licensing under nurses' boards requiring at the very least a minimum of training and education. It is further proposed that documentation requirements resort back to professional nursing documentation; funding be dependent on an predetermined minimum skill mix and staff/resident ratio; and the funding of residents be based on a minimum data set and untied from nursing practice. The professional nursing practice of assessment, planning, implementation, and evaluation of nursing care needs resorting to a nursing domain of knowledge, practice, accountability, responsibility, and documentation. If an acceptable quality of life is to be realised for residents in the residential aged care system, given that highly dependent residents are reliant on quality nursing care that is fundamentally imperative to their very quantity and quality of life, then changes in the residential aged care system and the nursing profession will be necessary. This thesis will contribute to opening up such dialogue between the government, the industry, and the nursing profession in Australia, and it also highlights areas of aged care nursing practice in need of further research.

Doctor of Philosophy (PhD) / Aged care is a critical public policy issue in Australia. The growing significance of the sector raises important and pressing questions about many aspects of care itself, the size of the labour force and employment relations. Answering these questions is vital, with demand for labour in the sector already outstripping supply and with demand certain to grow substantially. The implications of this labour shortfall for the sector have already been the subject of a number of key government reports. Although these reports have begun to construct a more detailed picture of the issues facing aged care workers and employers, significant gaps remain, most notably any explicit examination of approaches to the management of labour or the importance of labour law in determining these approaches. Despite the obvious importance and critical social and economic significance of the ageing population, we do not sufficiently understand many of the critical labour market features, workplace characteristics or management strategies which are evident in the aged care sector. This study seeks to build knowledge of employment and labour management in this growing and crucial sector at a decisive moment in history. It deepens our understanding of these issues and processes through a study of three residential aged care providers in New South Wales during the period from 2005 to 2009. The thesis specifically examines employer strategy in relation to the management of labour in the three cases. Further, it investigates the impact of the regulatory environment on these approaches. In doing so, the case studies reveal the intricate web of internal and external, direct and indirect, formal and informal regulation which shapes the management of labour within the sector. The complexity of the regulatory web in aged care demands the use of an explanatory framework which recognises that labour-management approaches are influenced by constraints not traditionally associated with the direct, legal regulation of employment relations. Consequently, regulation theory is applied here as an organising framework and as an interpretive prism for the research. This allows for an explicit acknowledgment of the importance of non-legal, informal and indirect regulation ‘at work’ in this sector. The study finds that in the period under review labour law was not the primary determinant of labour-management approaches in aged care. The case studies presented here show that it was, in fact, a second order consideration for aged care providers struggling with what they saw as insufficient funding, onerous ‘paperwork’ and staff recruitment and retention difficulties – in short a range of other regulatory influences. This study also shows that, despite the constraints imposed by these other regulatory modes, employers remained free to exercise their prerogative within the workplace; this, in turn, is revealed as a form of internal regulation in aged care.

The abuse of older people is a largely unrecognised and under acknowledged social problem in Australia. My major objective in undertaking the work, which is represented by the original published articles that comprise the thesis, was to make a scholarly and practical contribution toward the minimisation of 'elder abuse. This objective was achieved with the development and implementation of a series of studies that articulated and ameliorated elder abuse in Australia.The thesis provides an erudite synthesis of these studies, which fall into four themes that illustrate the nature and scope of my theoretical and professional work in elder abuse. Much of the work was guided by a conceptual framework of ways of knowing in nursing, and was underpinned by the principles and practice of community development and participatory community-based action processes.The outcomes of these studies include work with three stakeholder groups: professionals who deal with elder abuse, older people who are victims or potential victims of abuse, and those who perpetrate abuse on an older person. The work, illustrated in the four themes, includesthe articulation of elder abuse issues with West Australian aged care workersthe development of elder abuse protocols, policy guidelines and ethical principles, to guide professional practice in abuse prevention and interventionthe design and implementation of participative community programs to empower older people, and their carers, to resist being abused or abusing and to assist perpetrators stop their abusethe amelioration of abuse of nursing home residents by staff.The thesis situates my conceptual and clinical effort within the wider corpus of Australian knowledge and practice on elder abuse and contributes to addressing the social problem of elder abuse within the context of Australian aged care.

Thesis (D.Ed.)-- University of Technology, Sydney, 2005.

Background: Many interventions aim to alleviate well-documented problems of malnutrition in residential care homes and improve residents’ health and wellbeing. Despite some positive findings, little is known about how and why mealtime interventions might be effective, and in particular, what effects residents’ experiences of mealtimes have on health outcomes. Aim: The aim of this project was to gain an insight into residents’ experiences of mealtimes in order to inform the development of a mealtime intervention. By addressing the issues that impact on residents’ enjoyment of meals, interventions may target improvements in the health and wellbeing of residents more effectively. Methods: This thesis is comprised of three pieces of empirical work conducted using multiple methods. In a systematic review of stakeholder perceptions of mealtimes, five databases were searched from inception to November 2015, followed by thematic analysis of extracted data. In a second study, semi-structured interviews were conducted with eleven residents from four care homes in the South West UK. Thematic analysis was used to derive content and meaning from transcribed interviews. These studies informed the development of a staff-focussed training programme (study three) using the process of Intervention Mapping (IM) as a guide. The feasibility of this intervention was assessed using qualitative surveys and analysed using multiple methods. Fourteen staff from two care homes participated in the feasibility study, which investigated the deliverability of the training programme and the acceptability of its content. Findings: The systematic review and resident interview study revealed that the dining experience was a focal point for residents’ broader experiences of residing in a care home. Whilst meal quality and enjoyment impacted on the dining experience, the provision of care was pivotal in determining mealtime culture and resident agency within the home. This had implications for self-efficacy and social relationships, particularly in the context of transitioning from independent living to a care home community. These findings informed the development of a mealtime intervention, which was found to be deliverable and acceptable to staff. Conclusion: Mealtimes are a mainstay of life in a care home through which residents’ experiences are characterised, exemplified and magnified. Understanding how residents interact with one another, accommodating their preferences and encouraging autonomy may enhance their mealtime experiences. Evidence from the empirical work supports the development of interventions aimed at mealtime staff to improve resident self-efficacy. This thesis has established the necessary groundwork for a pilot trial and future definitive trial to assess resident (and staff) outcome measures including social (e.g., collective engagement) and psychological outcomes (e.g., wellbeing), as well as health outcomes (e.g., nutritional status).

Background Many trials in the USA, Canada, Europe and Australia have attempted to evaluate the effectiveness of preventive in-home health assessment and home care programs for older people. Trials have differed widely in their processes, including the dependence levels of subjects, assessment components and locations (clinic/home), intensity of case management (frequency of contact, length of follow-up period, scope of interventions) and methods of case management (telephone/visits). Preventive programs use valuable health resources and, although there has been inconclusive evidence of their effectiveness, programs combining preventive in-home health assessment and home care for older people have been introduced into public policy in Australia and internationally. Ongoing research is therefore essential in order to identify the positive benefits for older people, and establish their effectiveness with regard to health resource utilisation. Purpose The purpose of the study was to maintain the health status of older people living alone in the community by implementing a preventive health assessment and follow-up home care program. Research Design An experimental group was compared with a control group using a cluster randomised controlled trial methodology. Health outcomes were measured pre and post intervention, including health perception, functional ability, psychosocial status, client satisfaction, and health resource utilisation. Population and Sample The population for this study consisted of people aged 75 years and over who lived alone in Independent Living Units within managed retirement facilities, and who were highly independent in their activities of daily living. The final sample totalled 124, comprising of an experimental group (n=61) and a control group (n=63). The sample resided in South East Queensland. Intervention The intervention for the study "A Community Preventive Health Model for over 75s Living Alone" comprised of five major elements: 1) targeting before health and/or social crisis, and while community care needs were low; 2) linking clients with a community nurse; 3) comprehensive health assessments and identification of needs; 4) introduction of basic health care and community services and referrals if required; and 5) case management by three-monthly telephone contact. Assessments and case management were carried out by experienced community care registered nurses, and case management was performed for a one year period. The control group received health assessments and phone calls similar to the experimental group for data collection purposes, and to balance the risk of a Hawthorne effect due to regular contacts with participants. However all aspects of case management were omitted from all episodes of contact with the control group. For ethical reasons control group participants were supplied with a summary of their health assessment results to share with their GP if they wished. Data Collection and Instruments Measures of health perception, functional ability and psychosocial status occurred at two points (baseline and after 12 months). Measures of health resource utilisation, mortality and client satisfaction were measured after twelve months. A combination of several widely-used, valid and reliable instruments, as well as some newly developed data collection tools, were used to measure health outcomes. Data Analysis Independent group t-tests and Chi-square tests were used to examine for baseline differences between the experimental and control groups, and also to analyse health resource utilisation data at Time 2. A series of ANCOVA tests were applied to test the remaining hypotheses, so that the effects of Time 1 scores and potential confounding variables could be incorporated into the analyses. Results The experimental group and control group were homogenous at baseline for all demographic variables and all major outcome variables. The intervention model was applied for one year, with 66% (n = 40) in the experimental group having at least one unmet need identified and appropriate interventions undertaken. Only a small proportion of interventions (16%) were recorded as not being followed through by clients, and the majority (59%) resulted in needs being met or problems resolved. Results showed no benefits were gained from the program after one year for experimental group participants for the outcomes of health perception, functional ability, psychosocial status, health resource utilisation and mortality. However, the experimental group did show a statistically significantly higher level of satisfaction with care. Conclusions Comprehensive assessments performed by Registered Nurses with expertise in gerontology resulted in the identification of previously undetected unmet needs. When comprehensive assessment was combined with low intensity case management for a one year period, higher levels of client satisfaction with care were achieved. Therefore a model involving Registered Nurses with advanced knowledge and experience in aged care, working in collaboration with General Practitioners and community service organisations, could have considerable benefits in identifying unmet needs and improving client satisfaction. However, no client benefit was detected for quality of life outcomes, nor was a reduction in health resource utilisation found. This result from an Australian cohort is consistent with findings from many other international trials (Van Haastregt et al., 2000). It is possible that methodological issues are masking the effect of the intervention. Are we measuring appropriate outcomes? Are we expecting long-term outcomes in short time frames? Are we applying the model appropriately across a diverse older population? Further research to explore these questions is recommended for the future.

This grounded theory study investigated how registered nurses (RNs) managed problem-solving and decision-making in residential aged care facilities (nursing homes) in Western Australia. The outcome of the study was the substantive theory of situational positioning, the process used by the RN participants when they were trying to get things right .In-depth interviews were conducted with 25 purposefully selected registered nurses and nursing home management staff. The interviews were transcribed verbatim, and analysed using the constant comparative method. Other sources of data. guided by theoretical sampling. were selected documents such as government reports regarding aged care, and some field observations. Situational positioning was a process that involved physical. cognitive, emotional, and moral dimensions, and reflected how the RN participants acted and responded when dealing with situations at work. Situational positioning was conceptualised as occurring along two intersecting continua of behaviours, and these behaviours emerged from the data as four interrelated categories. Yielding and confronting represented the poles on a continuum of action-oriented behaviour, with being flexible and being rigid on a continuum that reflected more affective or attitudinal responses. The four categories that made up the positioning continua had both positive and negative meanings in relation to the actions and responses of the participants, depending on the particular situation. Yielding was a conceptual category that reflected participants' comments about stopping a particular action and trying something else or giving up completely and even leaving the situation. f he term confronting was used to describe participants' actions that were based on assertiveness that was seen as a constructive behaviour, or anger that tended to be non-productive. / Being flexible meant that the participants were responsive to changing situational variables, and this was usually seen as a desirable attribute of effective nursing practice in aged care. However, it could also mean being pliant and ready to compromise in order to get through situations when the participants realised that they would be unable to get things right. At the other end of the response axis, the term being rigid was defined as the opposite of being flexible, that is, having firmly fixed or set ways of responding. or a tendency to respond to situations in the same way in all circumstances. The basic psychosocial problem, being unable to get things right, had two properties. One property was temporal, in that the problem occurred when the participants were getting behind or running late because of having insufficient time. usually due to interruptions. The second property of the problem was more qualitative in that contextual and intervening conditions led the participants to feel that they were not doing things properly because of adverse conditions. Conditions that varied .situational positioning were those that led to the participants being unable to get things right, such as having insufficient time. working with unqualified carers. and trying to meet the differing expectations of various stakeholders. Situations that were easy for the participants to manage involved known routines and few, if any. interruptions. In those circumstances, si uational positioning was intuitive and the phases of recognising, prioritizing, and moving on were negotiated quickly. In more complex situations, or when significant interruptions occurred, the participants followed an alternative pathway, which involved recognising that something in the situation changed. then compromising. that is. choosing a new course of action. / Compromising required tolerance, as the participants adjusted their expectations of what could be achieved in the circumstances. Repositioning then occurred belore they moved on to the next task or to the end of their shifts. Moving on. the third phase in the process, involved persevering as they continued trying to get things right. The adverse conditions that prevailed in nursing homes during the time of this study impeded nursing practice and the delivery of consistently good standards of care for all residents. Situational positioning enabled the participants to persevere in their efforts to try to get things right, but their capacity to maintain the effort was eroded by the apparently unrelenting nature of the adverse conditions that existed in nursing homes. The main conclusion of this study was that the RN role in nursing homes in Western Australia was ill-defined, and inefficient in terms of best utilisation of nursing time. Recommendations included a review of the RN role in aged care and implementation of strategies that would enable aged care RNs to focus on their clinical roles.

This mailed survey of nurses in all (111) New South Wales aged care facilities with Huntingdon Disease affected residents, used a custom designed questionnaire in a triangulated exploratory design. It was undertaken by an HD specialist nurse into the previously un-researched field of the nursing challenges in that setting. Knowledge was sought, through descriptive and correlational analysis of fixed choice and open-ended questions, of the facts of the affected resident profile (N=63). Similarly, nursing opinions were obtained on the following unsatisfactory aspects of care provision, the impact of internal resources and the HD nursing role and its support. Results are discussed in some detail. Overt evidence of stigmatisation was not evident. Approximately 32 additional long stay HD beds are needed plus more equipment and education for the aged care facilities. The outreach model of support was strongly endorsed. / Master of Nursing (Hons)