China is currently facing what I expect to be its most significant challenge to date - a crisis in the care of its rapidly ageing population. The causes of this crisis are complex and multi-faceted and its implications far-reaching from the social, economic and political perspectives. This thesis examines the causes and consequences of the impending aged care crisis in China, with a particular focus on the urban elderly. In addition to extensive interviews with government officials, a sample of 2,000 retires and their children were surveyed in Shanghai as part of my research. My findings from the Research Survey and Questionnaire, together with my observations from site visits to numerous aged care crisis and the associated problems. Of primary concern is the fact that the Chinese government does not have in place an appropriate aged care structure nor a strategy to implement systems to cope with the impending crisis. I conclude that it is imperative the Chinese government recognises both the immediacy and scale of the crisis and acts accordingly. Failure to do so may result in both significant social unrest and severe economic consequences. Recommendations are offered for consideration by the Chinese government in an effort to manage the impending aged care crisis in China. / Doctor of Philosophy (PhD)

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

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.

<p>Trots att det finns en lag om att bevara patientens rättigheter, finns ändå bemötandeproblem i vården som har varit en följetong i svensk media. Bemötande i vården bör anpassas till patientens behov, där empati är en grundläggande aspekt inom vården. Syftet med denna studie var att studera hur bemötande sker mellan vårdpersonalen och de äldreboende. Fyra timmars fältobservationer gjordes med tio vårdpersonalen och fyra intervjuer med fyra vårdanställda på ett äldreboende. Rådata analyserades och en triangulering gjordes med grundad teori. Resultaten visade att bemötande skedde med empati och kärnprocessen handlade om att empati är bundet till psykisk samt fysisk närhet. Det förhållningssätt som uttrycks i lagar, policybeslut och i själva professionen samverkar med vårdpersonalens individuella attityder och värderingar i hur man bemöter människor i beroendeställning. I studien diskuteras hur empati och närhet är en förutsättning för att vårdpersonalen ska lyckas i sitt arbete som professionella hjälpare.</p>

Trots att det finns en lag om att bevara patientens rättigheter, finns ändå bemötandeproblem i vården som har varit en följetong i svensk media. Bemötande i vården bör anpassas till patientens behov, där empati är en grundläggande aspekt inom vården. Syftet med denna studie var att studera hur bemötande sker mellan vårdpersonalen och de äldreboende. Fyra timmars fältobservationer gjordes med tio vårdpersonalen och fyra intervjuer med fyra vårdanställda på ett äldreboende. Rådata analyserades och en triangulering gjordes med grundad teori. Resultaten visade att bemötande skedde med empati och kärnprocessen handlade om att empati är bundet till psykisk samt fysisk närhet. Det förhållningssätt som uttrycks i lagar, policybeslut och i själva professionen samverkar med vårdpersonalens individuella attityder och värderingar i hur man bemöter människor i beroendeställning. I studien diskuteras hur empati och närhet är en förutsättning för att vårdpersonalen ska lyckas i sitt arbete som professionella hjälpare.

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

Thesis (Ph. D.)--University of Missouri-Columbia, 2000. / Typescript. Vita. Includes bibliographical references (leaves 194-200). Also available on the Internet.

Thesis (Ph. D.)--University of Missouri-Columbia, 2000. / Typescript. Vita. Includes bibliographical references (leaves 194-200). Also available on the Internet.

Thesis (M. Arch.)--University of Hong Kong, 1995. / Includes special study report entitled: Palliative design for terminal ill patients. Includes bibliographical references.