While the concept of person-centred care in dementia has been around for 15 years or more and has attracted much interest and enthusiasm, aged care facilities continue to have difficulty in actually implementing and maintaining person-centred practices. In this study I explore the experience of one aged care facility in order to identify the barriers to changing care practice. The research took place in an ethno-specific (Jewish) aged care facility, Star of David, which was in the process of setting up a program for its residents with dementia based on person-centred principles. The methodology used in the research study was ethnographic, involving participant observation and interview, with a particular focus on a limited number of participants: four residents and their families, four senior staff, four personal care attendants and the executive director. Interviews were also conducted with staff members from three other aged care facilities. The findings showed that Star of David was unable to bring about substantial change in its care practices, while the external interviews and the literature suggest that other facilities have similar difficulties. I identify three major types of barrier: procedural barriers within the institution itself; (government) policy; and barriers relating to hegemonic values and beliefs which underpin established health care practice. These three types of barrier interact with and reinforce one another. I conclude that if we are to change care practice in institutions, we must address all of these barriers at the same time. Finally, I suggest that person-centred care itself, which continues to place emphasis on professional service provision, may only be the beginning of necessary change. In order to be truly person-centred, we need to move towards a more community based or public health approach which recognizes the need of all persons to be treated both as significant individuals and accepted as part of a community.

This study has explored the culture of nursing home life as experienced by elderly nursing home residents in Taiwan in order to understand, describe and interpret their care needs. In December 2006, the elderly represented 10% of the total population of Taiwan, and this proportion is predicted to increase steadily. In turn, this increase suggested that Taiwan would see ever greater numbers of elderly people with chronic illnesses and physical and mental disabilities. To care for these people, nursing homes have expanded rapidly throughout Taiwan. However, the quality of care provided in these nursing homes has become an urgent matter of concern. Though meeting the residents' care needs is essential for the provision of the best quality care, a review of the available literature shows that the care needs of the elderly residents within the nursing home context are poorly understood, both in Taiwan and internationally. To address this gap in present understanding, a focused ethnographic approach, using participant observation, in-depth interviews and a review of documents, was undertaken between July 2005 and February 2006. The key participants were sixteen elderly residents who were 65 years old and over, had no cognitive impairment and had lived in the nursing home selected for the present study for at least six months. Eight nurses, six nursing assistants, one private nursing assistant, one orderly, one physician's assistant and four family members were also interviewed, with questions put to them being based on the data generated from the observation and in-depth interviews with the elderly residents. All interviews were recorded on a digital recorder and transcribed verbatim. Following this, the data gathered from the in-depth interviews, the participant observation and the review of documents was sorted and indexed using the qualitative software program, NVivo7. A five-step analytic process, based on concepts discussed in previous literature, was used to trace the emerging themes. Nine major care needs were identified by the elderly residents. These included basic functional care needs, emotional support care needs, economic care needs, psychological care needs, environmental care needs, social support care needs, professional care needs, religious care needs and preparation for death care needs. Three themes of nursing home culture were generated; these were collective life, care rituals and embedded beliefs. The findings of the study indicate that the structure and culture of the nursing home contribute to several care needs remaining unmet. In addition, the results reveal that it is necessary to satisfy economic care needs before other care needs can be resolved. These findings fill an important gap in nursing knowledge regarding the delivery of better quality care in nursing homes. They also provide relevant information to nursing practice, nursing education and Taiwanese long-term care policy-making, and provide a sound basis for future residential care research.

The global trend towards an ageing population presents challenges for health-care professionals, including registered nurses (RNs). In Taiwan, health care policies relating to the aged and to gerontological nursing are still in the early stages of development. Integral to this development is the evolving definition of the clinical role of RNs who make a major contribution to aged care. Using data from in-depth interviews of 29 RNs working across eight nursing homes, this grounded theory study examines the factors that shape the care work of RNs in long-term aged care in Taiwan. The objectives of this study were to: * examine the work-experience perceptions of RNs employed in nursing homes in Taiwan * explore the factors that influence the delivery of nursing care to the aged by RNs * explain the events that constitute nursing practices in aged care provision that have an effect on the roles of RNs, and * develop a theoretical proposition that can guide future nursing practice in aged care. Grounded theory and symbolic interactionism are the complementary methodologies selected to underpin this study. The perspective of grounded theory allows for a critical investigation of the social processes that are integral in shaping the perspectives of RNs who work in Taiwanese nursing homes. The application of the theory of symbolic interactionism facilitates an exploration of the roles of RNs in this context and of the different meanings for individuals in the various situations they confront. Organizational factors and interactions that shape the role of RNs in the working environment of aged care are highlighted in the interaction between the data and the theory. The core category that emerged from the study was searching for an identity. This core process reflects ambivalence in the perceptions of RNs in describing and explaining the nursing role in Taiwanese nursing homes. Five categories that bring some greater understanding of this ambivalence are: coming to know, doing anything and everything, negotiating the work role, dealing with the system, and learning by being there. The specific intention of this study was to extend our understanding of nursing work and the delivery of care to older people in nursing homes in Taiwan. The findings of this study will contribute to the development of an educational framework that may be applied to improve nursing practices in nursing homes. These findings also have the potential to make a positive contribution to aged health care policy-making in Taiwan.

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An aging population is one common challenge faced by many developed countries including Australia. The Australian government has realised that the existing healthcare system must be improved to provide better support longer-term for the healthcare needs of this population. This research examines one such opportunity by suggesting a reform on how the care needs of residents living in Australian residential aged care facilities (RACF) are assessed. A recent study has shown that the current assessment system, known as the Residential Classification Scale (RCS), is subjected to high administrative procedural overhead costs and significant deviations in assessment results. This thesis documents a technical feasibility study of a novel method aimed to solve issues related to the time demands and subjectivity of the RCS through the design and implementation of a Wireless Sensor Network (WSN). This WSN is engineered to unobtrusively collect data from wireless sensor nodes either embedded in the RACF environment or attached to the resident??s body. The collected data can be potentially used to provide automatic and accurate care level assessments for the resident. The methodology of preparing and conducting the experiments to prove the hypotheses is justified and described, including the experimental instruments and procedures involved. The results show that this WSN surpasses similar research systems in terms of its application scale, the number and types of sensor nodes involved and the complexity of its hardware and firmware architectures. The major contributions of this thesis are: ?? The WSN developed satisfies certain technical requirements to be declared fit for use in a mock Australian RACF. ?? The WSN provides high sensor detection accuracies (between 88% and 100%), superior location tracking capability (94.75%) and activities of daily living inference capability over similar studies. Opportunities for further improvements of this WSN include: ?? Fine tuning the detection accuracy of Passive Infra-red (PIR) motion sensors. ?? Minimising the down time of the sensor nodes due to firmware memory leak. ?? An extra location tracking mechanism to improve location accuracy determination.

Four different case management programs delivered by UnitingCare Community Options (UCCO) in the eastern suburbs of Melbourne were examined against the expectations of case management as a policy solution to a range of perceived policy problems at the micro-, meso- and macro-levels. The micro-level expectations were related to client and family experiences of the service system and outcomes. At the meso-level expectations were focused on perceived service delivery problems such as poor matching of services to the needs of ‘complex’ clients including a lack of integration, flexibility and responsiveness to clients’ needs and preferences. Perceived macro-level policy problems were concerned with a variety of issues including increasing rates of institutionalisation, increasing costs to governments, lack of economic efficiency and the desire to create market or quasi-market conditions in the community care service delivery sector. (For complete abstract open document)

An aging population is one common challenge faced by many developed countries including Australia. The Australian government has realised that the existing healthcare system must be improved to provide better support longer-term for the healthcare needs of this population. This research examines one such opportunity by suggesting a reform on how the care needs of residents living in Australian residential aged care facilities (RACF) are assessed. A recent study has shown that the current assessment system, known as the Residential Classification Scale (RCS), is subjected to high administrative procedural overhead costs and significant deviations in assessment results. This thesis documents a technical feasibility study of a novel method aimed to solve issues related to the time demands and subjectivity of the RCS through the design and implementation of a Wireless Sensor Network (WSN). This WSN is engineered to unobtrusively collect data from wireless sensor nodes either embedded in the RACF environment or attached to the resident??s body. The collected data can be potentially used to provide automatic and accurate care level assessments for the resident. The methodology of preparing and conducting the experiments to prove the hypotheses is justified and described, including the experimental instruments and procedures involved. The results show that this WSN surpasses similar research systems in terms of its application scale, the number and types of sensor nodes involved and the complexity of its hardware and firmware architectures. The major contributions of this thesis are: ?? The WSN developed satisfies certain technical requirements to be declared fit for use in a mock Australian RACF. ?? The WSN provides high sensor detection accuracies (between 88% and 100%), superior location tracking capability (94.75%) and activities of daily living inference capability over similar studies. Opportunities for further improvements of this WSN include: ?? Fine tuning the detection accuracy of Passive Infra-red (PIR) motion sensors. ?? Minimising the down time of the sensor nodes due to firmware memory leak. ?? An extra location tracking mechanism to improve location accuracy determination.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第20085号 / 社医博第76号 / 新制||社医||9(附属図書館) / 33201 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 福原 俊一, 教授 佐藤 俊哉, 教授 古川 壽亮 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

The intent of my project is to recognize the importance of the residential care home administrator by providing him or her with a training curriculum in order to have additional knowledge upon which to base program planning. Perhaps, someday, a unique type of care outside as well as inside California.

Yes / This study assessed the effects of a person-centred care based psycho-educational intervention on direct care workers' communicative behaviours with people with dementia living in aged care facilities. An experimental study with a pre-posttest control group design was conducted in four aged care facilities. Two experimental facilities received an eight-weekly psycho-educational intervention aiming to develop workers’ knowledge about dementia, person-centred care competences and tools for stress management; control facilities received an education-only, with no support to deal with stress. A total of 332 morning care sessions, involving fifty-six direct care workers (female, mean age 44.72±9.02), were video-recorded before and two weeks after the intervention The frequency and duration of a list of verbal and non-verbal communicative behaviours were analysed. Within the experimental group there was a positive change from pre to post-test on the frequency of all workers’ communicative behaviours. Significant treatment effects in favour of the experimental group were obtained for the frequency of inform (p<0.01, ƞ2partial=0.09) and laugh (p<0.01, ƞ2 partial=0.18). Differences between groups emerged mainly in relation to non-verbal communicative behaviours. The findings suggest that a person-centred care based psycho-educational intervention can positively affect the direct care workers’ communicative behaviours with residents with dementia. Further research is required to determine the extent of the benefits of this approach. / Foundation for Science and Technology