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

This study reports the positive and negative aspects identified by registered nurses (RNs) working with older people in public hospital aged care units and was conducted in 4 public hospitals in Sydney, Australia. Qualitative data using questionnaires and telephone interviews was collected from 26 female and 4 male RNs of which 46% (n 14) had worked in an aged care unit for 10 years or more. The participants identified positive perceptions within three major themes: a genuine liking of older people; the stories older people tell and the complexity of the older patient’s illnesses. Positive responses were a focus as it was identified that this was a gap in the literature which required addressing at the time. These findings are significant and have implications for nursing practice for several reasons: Data was collected exclusively from RNs and focused on their positive perceptions about aged care nursing in public hospitals. Participants reported a genuine liking for older people. Patients’ telling their stories was reported by 60% (n 18) of participants as being interesting in their work and meaningful to the patient and should be considered more as a therapeutic process during hospitalisation to assist support and enhance patient outcomes and therapy. The participants reported that aged care nursing is complex, rewarding and requires mature nurses, with current nursing knowledge and skilled in the art of caring for older people. These findings can be used to improve recruitment and retention of RNs within aged care nursing. / Master of Health Science (M.Sc.(Hons) Health)

Depression is poorly recognised, under-assessed and under-treated in patients receiving palliative care for a life-limiting illness. There are barriers to assessment and diagnosis, and limited access to specialist clinicians who might assist in these complex assessments and who could provide options for treatment. The three studies presented, using different research methodologies, and using both qualitative and quantitative analysis, seek to clarify these issues and to provide some solutions. A questionnaire was sent to all Palliative Care Services (PCS) in Australia. Questions included what part specialist psychological clinicians played in multi-disciplinary team meetings and in the treatment or coordination of patient care. Very few PCS used a valid screening instrument for psychological distress and very few had regular support from a psychiatrist or psychologist. Many did not have access to social work support. There are two competing issues with regard to recognising and assessing depression in palliative populations. A rapid reliable screen that points to a likely problem would be useful, but also there is a need to understand something of the patient experience of depression. In the second study, the one- and two-item screening instruments widely used in palliative care are examined and limitations that have been found in other settings are confirmed. A new novel screening tool is developed from this data and tested empirically. This algorithm is short, has good psychometric properties and is validated for an Australian palliative care population. Depending on the response pattern it is possible to identify that a particular patient has significant symptoms of depression by asking between one and four questions. Professional carer and patient acceptability of the questions is high. The understanding of the experience and symptom profile of depression in Australian palliative care patients is addressed in the third study. Patients and family carers were recruited prospectively from palliative care and oncology ambulatory clinics of two teaching hospitals in an Australian capital city. The Geriatric Depression Scale (GDS) was administered to the patient and the Collateral Source version of this instrument was asked of the carer. A subset of this sample completed the measures twice. The results using this 30-item scale were then compared with all the known previously published short versions of this scale. Two short forms met as many psychometric criteria as the longer forms. None of the versions of the GDS showed sufficiently high correlations between carer-completed and patient-completed forms. The frequency of symptoms was also assessed. Patients more frequently reported fatigue and anhedonia than depressed affect. Despite many screening instruments being available for depression, their use is limited in Palliative Care Services. Although these studies have validated several options for Australian palliative care patients, the issues behind the low uptake rates for screening have not been resolved. The final chapter of this thesis constructs known and potential barriers into a logical structure and then offers some solutions to improve access to mental health professionals by considering service models and applying this theory to the problem of depression and its assessment in palliative care populations.

<p>Betydelsen av ett gott chefskap inom äldreomsorgen är av stor vikt för medarbetarna, de boende och verksamheten. Omvårdnadsarbetet påverkas av chefens sätt att arbeta och det krävs därför att chefen är medveten om vad som utgör ett bra chefskap. Intervjuerna i denna studie är utförda med sju enhetschefer inom äldreomsorgen i Sverige. Syftet var att undersöka hur enhetschefer inom svensk äldreomsorg uppfattar sitt chefsarbete inom detta verksamhetsområde. Resultatet visade att arbetssätt, relationer, förhållningssätt och utvecklingsarbete är faktorer som enligt dessa chefer utmärker ett bra chefskap. Förutsättningar för ett bra chefskap var goda arbetsvillkor, motivation, stöd, samarbete, personliga egenskaper och upplevelser av chefskapet.</p>

<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.

Betydelsen av ett gott chefskap inom äldreomsorgen är av stor vikt för medarbetarna, de boende och verksamheten. Omvårdnadsarbetet påverkas av chefens sätt att arbeta och det krävs därför att chefen är medveten om vad som utgör ett bra chefskap. Intervjuerna i denna studie är utförda med sju enhetschefer inom äldreomsorgen i Sverige. Syftet var att undersöka hur enhetschefer inom svensk äldreomsorg uppfattar sitt chefsarbete inom detta verksamhetsområde. Resultatet visade att arbetssätt, relationer, förhållningssätt och utvecklingsarbete är faktorer som enligt dessa chefer utmärker ett bra chefskap. Förutsättningar för ett bra chefskap var goda arbetsvillkor, motivation, stöd, samarbete, personliga egenskaper och upplevelser av chefskapet.

This study examined the behaviors relating to the utilization of prescription and over-the-counter medications in a small group of elderly subjects in the 65 years and over age range. This group was attending an Elderhostel at Western Oregon State College during the summer of 1991, when the information was obtained. The objectives of this study were to ascertain specific medication taking behaviors, and whether or not directions were adhered to as prescribed by physicians for this highly educated group, or if their behaviors were similar to those referred to in the literature for all elderly. A sample of 38 elderly was obtained during an Elderhostel Wellness Vacation at Western Oregon State College in Monmouth, Oregon during July, 1991. Subjects completed questionnaires regarding medication-taking behaviors as part of a wellness class session regarding the safe use of medications. Questionnaires were filled out prior to the class discussion. Data were assembled using one survey instrument with questions relating to medication usage. Descriptive statistics using histograms showing frequency distributions were used for data analysis. Sixty-five percent of this group were taking prescription medications and sixty-eight percent of this group were taking over-the-counter medications. Medications were being obtained from more than one physician and more than one pharmacy. The subjects took fewer doses of medications per day and less medication per dose than prescribed. Medications were discontinued prematurely if feeling better or worse. Leftover medications from previous prescriptions were being taken. Outdated or expired medications were being taken. Alcoholic beverages were being used in conjunction with the use of prescription medications. In some cases, prescriptions were not filled because they were considered to be unnecessary. Recommendations for education and future research in the problematic area of drug use in the elderly include: 1) More time spent by health care professionals to educate the elderly in the correct and safe use of medications; 2) Community health promotion programs targeted at the well elderly; 3) Personalized "brown bag" medication counselling sessions; 4) Medication education programs at Elderhostels throughout the country; 5) Education programs through the American Association of Retired Persons; and 6) Further studies of larger groups of well-educated, healthy and active elderly. / Graduation date: 1993

Cognitive impairment among older adults with type 2 diabetes may worsen health outcomes via negative impact on compliance with medical self-care recommendations. Results of several previous studies indicate that cognitive deficits are present in older European American adults with type 2 diabetes under some conditions, particularly related to glucose dysregulation (as evidenced by high glycated hemoglobin, i.e., HbA1c). Despite the fact African Americans are disproportionately affected by diabetes and suffer significantly greater numbers of complications and more severe complications relative to European Americans, no published studies have examined cognitive functioning among older African American adults with type 2 diabetes. Further, markers of systemic inflammation have been associated with cognitive impairment in several conditions, but this relationship has not been examined in older adults with type 2 diabetes. The purpose of the present study was to determine whether: 1) cognitive deficits are present in older African American adults with type 2 diabetes, and whether the deficits are related to 2) glucose dysregulation and 3) systemic inflammation. Several cognitive domains, including verbal memory and executive functions, were assessed in 71 African Americans with type 2 diabetes who ranged from 60 to 80 years of age. Exclusionary criteria included dementia, depression, neurological disease, or brain injury. Also measured were HbA1c and two markers of systemic inflammation: C-reactive protein (CRP) and interleukin-6 (IL-6). Results showed that higher HbA1c was significantly associated with poorer performance on several measures of executive function and verbal memory measures that tap executive function. Higher IL-6 was significantly associated with slower motor function and higher semantic fluency. Higher CRP was significantly associated with improved performance on measures of phonemic fluency, psychomotor speed and mental flexibility/working memory, and fine motor dexterity, but only for those with extremely high levels of CRP; when those participants were removed from the analyses, CRP was inversely related to cognitive performance.

Older adults have historically utilized mental health services at substantially low rates. Unfortunately, though professional, policy, and other recent developments portend an increase in service use, there has been scant empirical attention devoted to the current or recent utilization of mental health treatment by the elderly, and almost nothing is known about the correlates of mental health need and service use among older adults. Accordingly, the present study examined patterns of serious mental illness (SMI), specific mental health syndromes, and service use among older (65+) and younger (18- 64) adults throughout the United States, and the extent to which various factors predict mental health need and the use and magnitude of mental health treatment. In addition, the study examined factors related to unmet need, as well as age group differences in perceived benefit from treatment. The findings reveal that older adults were three times less likely than their younger counterparts to receive any outpatient mental health treatment. Only 2.5% of older individuals utilized any outpatient mental health service in the past year, versus 7.0% of younger adults. The results indicate that the low rate of utilization by older adults may be partly a function of limited subjective mental health need. Prevalence estimates for SMI and all specific mental health syndromes, with the exception of agoraphobia, were markedly lower in the older than the younger cohort. Importantly, though mental health problems appear to be significantly undertreated in older and younger age groups, the study also reveals that those older and younger adults that make it into services typically benefit considerably from treatment. It is hoped that the knowledge yielded by the current study will promote efforts to enhance mental health care access and reduce the long neglected mental health needs of the nation’s elderly population. Several factors related to mental health need and service use were identified in the study that may assist policy, planning, and outreach efforts aimed at increasing service access.