Constructing Normalcy in Dementia Care: Carers' Perceptions of Their Roles and the Supports They Need.

BACKGROUND AND OBJECTIVES: People with dementia are critically dependent on their carers when accessing and utilizing health care. To inform health care development and delivery, we aimed to explore carers' perceptions of their role in caring for a family member with dementia and to identify carers' skills and attributes and factors impacting on care. RESEARCH DESIGN AND METHODS: We used semistructured interviews to collect data from 25 carers supporting older adults with dementia. Data were thematically analyzed and the paradigm model was used to guide theory development. RESULTS: "Constructing normalcy" was central to all carers did, impacted by stage of life and relationship status and driven by a holistic focus on their care-recipient's quality of life. Goals guiding care were: keeping the peace; facilitating participation, happiness and independence; and ensuring safety. Enablers included: social contact; knowledge; and quality social services. Barriers included health and legal issues; symptoms of dementia; and reduced knowledge. These goals kept the peace and reduced stress for the cared-for person, but often at the cost of unrelenting responsibility and loss of carers' original roles. Discussion and Implications: As carers are so critical to the access and uptake of health care of those with dementia, health professionals and services need to support carers in their quest to construct normalcy. Our findings provide guidance to assist in ensuring appropriate support and understanding of carers work in order to optimize dementia health care delivery.

The Parenting Journey: Daily Parental Management in Families with Young Children.

Transitioning to parenthood and establishing a family are significant life events, and although an expected and normal part of adult life, it is a time of stress, change, and learning. The family has been well-studied with regard to developmental norms and the diagnosis and treatment of physical, cognitive, and emotional problems. However, little is known about how parents of young children establish, manage, and maintain their families on a daily basis. Social constructivist grounded theory was used to examine day to day parental management in families with young children. A theory, adjusting and redefining priorities, was developed to explain how parents make decisions related to the health and well-being of family members. A group of 24 New Zealand parents was interviewed about their daily management in families where the eldest child was aged no older than 3 years. Findings of this study revealed that parents used 4 overarching and constantly interacting viewpoints to consider situations: the personal, the parent, the parent unit, and the family unit. Their learning went through cycles of intensity and relaxation as parents considered their short term and long term priorities. Sometimes major changes to family structures and processes were required to maintain family stability, and sometimes the adjustments needed were relatively minor. These dimensions contributed to parents' continuous efforts to meet the needs of all family members and to create a unique family environment that encompassed the guiding principles upon which parents made their decisions. This study highlights the need for health professionals to recognize the unique, complex and dynamic decision-making process parents are already engaged in when managing their families.

"Working towards being ready": A grounded theory study of how practising midwives maintain their ongoing competence to practise their profession.

OBJECTIVE: to present a grounded theory research study explaining how New Zealand midwives maintain their ongoing competence to practise their profession. DESIGN: grounded theory, an interpretive emergent research methodology was used to examine the process of maintaining competence in midwifery practice. SETTING: New Zealand urban and rural practice settings. PARTICIPANTS: twenty-six midwives from across New Zealand were interviewed and asked about maintaining their competence to practise. Five midwives were interviewed twice, to explore the emerging findings and as one method of member checking. FINDINGS: the grounded theory of 'working towards being ready' describes a continuous process in which midwives engage as they work to maintain practice competence. The component parts comprise professional positioning, identifying needs, strategizing solutions and reflecting on practice. The process is contextual, diverse and is influenced by the practice setting where the salient conditions of resourcing, availability and opportunity for engagement in activities are significant. KEY CONCLUSIONS: across the midwifery profession, midwives in New Zealand are currently working under the generic umbrella of midwifery practice. Midwives work across a range of practice arenas in diverse ways focussed on providing safe care and require a range of professional development activities germane to their area of practice. When the midwife has access to professional development pertinent to their practice, women and the profession benefit. As there is diversity of practice, then mandated processes for ongoing competence need to have flexibility to reflect that diversity. IMPLICATIONS FOR PRACTICE: midwives engage in development that allows them to remain current in practice and that enables them to provide appropriate care to women and their babies. As a consequence they can develop expertise in certain aspects of midwifery. Mandated processes that require engagement in activities aimed at demonstration of competence should be evaluated and tailored to ensure they meet the needs of the developing profession.

Current role challenges in New Zealand aged residential care: the potential consequences for healthcare assistant role expansion.

BACKGROUND: Challenges facing healthcare assistants in aged residential care are a focus of global debate. These challenges involve remuneration, education, skill mix, work conditions and organisational structures. OBJECTIVES/AIMS: We enter the discussion by acknowledging current work, education and remuneration for healthcare assistants. We then consider the supervisory relationships between registered nurses (RNs), enrolled nurses (ENs) and healthcare assistants, educational levels for RNs, ENs and healthcare assistants, and the interplay between organisation and practice in aged residential care. We suggest that improving work for the healthcare assistant has the potential to lead change in all role levels. DESIGN: Discussion paper. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: We argue that adjustments to work structures, education and skill advancement of RNs, ENs and healthcare assistants could improve staff working conditions and clarify practice boundaries. The ultimate result is likely to be an improvement to quality of care and the life of residents in aged residential care.

Do gerontology nurse specialists make a difference in hospitalization of long-term care residents? Results of a randomized comparison trial.

Residents of long-term care facilities have highly complex care needs and quality of care is of international concern. Maintaining resident wellness through proactive assessment and early intervention is key to decreasing the need for acute hospitalization. The Residential Aged Care Integration Program (RACIP) is a quality improvement intervention to support residential aged care staff and includes on-site support, education, clinical coaching, and care coordination provided by gerontology nurse specialists (GNSs) employed by a large district health board. The effect of the outreach program was evaluated through a randomized comparison of hospitalization 1 year before and after program implementation. The sample included 29 intervention facilities (1,425 residents) and 25 comparison facilities (1,128 residents) receiving usual care. Acute hospitalization rate unexpectedly increased for both groups after program implementation, although the rate of increase was significantly less for the intervention facilities. The hospitalization rate after the intervention increased 59% for the comparison group and 16% for the intervention group (rate ratio (RR) = 0.73, 95% confidence interval (CI) = 0.61-0.86, P < .001). Subgroup analysis showed a significantly lower rate change for those admitted for medical reasons for the intervention group (13% increase) than the comparison group (69% increase) (RR = 0.67, 95% CI = 0.56-0.82, P < .001). Conversely, there was no significant difference in the RR for surgical admissions between the intervention and comparison groups (RR = 1.0, 95% CI = 0.68-1.46, P = .99). The integration of GNS expertise through the RACIP intervention may be one approach to support staff to provide optimal care and potentially improve resident health.

Moving the agenda forward: a person-centred framework in long-term care.

BACKGROUND: Internationally, the role of the registered nurse (RN) in long-term care (LTC) settings has evolved in response to the demands of governmental and organisational priorities. In stark contrast to the regulatory mandates, a person-centred care approach in LTC settings would require different outcomes, processes and competencies of the RN. AIMS: This article explores the implications of defining the RN's role in delivering person-centred care in LTC homes. METHODS: Based on a review of the literature, we present a framework that can be used to gather evidence on the outcomes, processes of care and competencies required of RNs to lead their teams to person-centred LTC homes. RESULTS: The development of the framework highlighted several issues: (i) current measures of quality in LTC settings focus on health outcomes and avoiding adverse events rather than on resident quality of life and well-being, which influences the RN's practice; (ii) person-centred care has emerged as a focus of care, yet measures currently developed are limited, and thus, new outcomes are proposed; (iii) to practice in a person-centred way, RNs must work through others on their team to ensure that staff truly relate to their residents, tailor approaches based on the remaining abilities of the residents and manipulate environments to match the competence of the individual, while focusing on residents' personhood and (iv) competencies of RNs to deliver person-centred care include leadership, facilitation, clinical excellence and critical thinking skills. CONCLUSIONS: RNs need to be supported, allowed and encouraged in redesigning their role, to work to their full capacity if they are truly to support person-centred care in LTC settings.

Oral healthcare for older people: 'I can't afford not to go to the dentist, but can I afford it?'.

AIM: The purpose of this study was to examine challenges older people encounter in maintaining satisfactory oral health status. METHOD: This interpretive qualitative study involved 19 in-depth interviews with participants aged 65 to 87 years. Data were examined using a three-level analytic process. NVivo Qualitative Software assisted data management. RESULTS: Participants in this study didn't 'just go' to the dentist. Much effort went into solving the dilemmas and tensions of maintaining their oral health through a process of option balancing. Balancing personal and financial costs, they continually assessed their 'bottom line'. They negotiated issues of: dental cost versus service quality; basic treatment versus functionality and social appearance; future living costs versus current dental costs; and 'how long will it need to last' versus 'how long will I live'? CONCLUSION: Problems exist in the provision of affordable oral health care for the older population in Aotearoa New Zealand. They struggle to afford dental care. They receive little financial support to access oral healthcare services and are dependent on developing their own strategies to enable such care. Health professionals and policy decisionmakers' challenge is to bridge this gap.