Creating cultures of care: exploring the social organization of care delivery in long-term care homes

Context: As a result of changing demographics, the number of older adults living in long-term care homes (LTCHs) is expected to rise dramatically. Thus, there is a pressing need for better understanding of how the social organization of care may facilitate or hinder the quality of work-life and care in LTCHs. Objectives: This study explored how the social organization of work influences the quality of work-life and care delivery in LTCHs. Method: Institutional ethnography followed by theory building provided the conceptual underpinnings of the methodological approaches. Participants included 42 care team members who were employed by one of three participating LTCHs. Data were derived from 104 hours of participant observation and 42 interviews. Findings: The resident care aides (RCAs) were found to rely on supportive work-teams to accomplish their work successfully and safely. Reciprocity emerged as a key feature of supportive work-teams. Management practices that demonstrated respect (e.g., inclusion in residents’ admission processes), recognition, and responsiveness to the RCAs’ concerns facilitated reciprocity among the RCAs. Such reciprocity strengthened their resilience in their day-to-day work as they coped with common work-place adversities (e.g., scarce resources and grief when residents died), and was essential in shaping the quality of their work-life and provision of care. Discussion: The empowerment pyramid for person-centred care model proposes that the presence of empowered, responsive leaders exerts a significant influence on the cultivation of organizational trust and reciprocating care teams. Positive work-place relationships enable greater resilience amongst members of the care team and enhances the RCAs’ quality of work-life, which in turn influences the quality of care they provide. Limitations: Whether there were differences in the experiences, opinions, and behaviour of the people who agreed to participate and those who declined to take part could not be ascertained. Further research is required to determine and understand all of the factors that support or inhibit the development of empowered leaders in LTCHs. Implications: Cultures of caring, reciprocity and trust are created when leaders in the sector have the support and capacity to lead responsively and in ways that acknowledge and respect the contributions of all members of the team caring for some of the most vulnerable people

Long-term care in rural Alberta: exploring autonomy and capacity for action

Context: Since the 1990s, Alberta, Canada has seen considerable restructuring to health and long-term care (LTC) services. Most LTC research is conducted in urban centres. As a result, little is known about the effects that restructuring has had on rural LTC homes. Objective(s): In this article, we outline our findings related to autonomy and capacity for action in rural LTC homes. Method(s): We conducted a multi-site comparative case study. Using rapid ethnography, we conducted weeklong site visits at three rural LTC homes. This involved two types of data collection: semi-structured qualitative interviews and field observations. We used a feminist political economy lens to analyze the data. Findings: Our findings offer insights into how rural LTC staff are empowered to create change and/or constrained from doing so. We outline these findings at macro, meso, and micro levels of analysis and conclude that a combination of site-level and systemic factors contribute to a LTC home’s level of autonomy and capacity for action. Limitations: Our findings reflect experiences and observations at three LTC homes at three distinct points in time. Though the data provide rich descriptions, they do not provide an exhaustive account of the strengths and challenges of rural LTC. Implications: Community resources, local industries, and other socioeconomic and organizational factors contribute to a community’s response to LTC restructuring and their ability to make change and ruralize their LTC provision. These factors, and the heterogeneity of rural communities, should be taken into consideration during decision-making about rural health policy and service provision

Staff engagement for practice change in long-term care: evaluating the Feasible and Sustainable Culture Change Initiative (FASCCI) model

Context: Interventions aimed at increasing the provision of person-centred care in long-term care (LTC) homes, that do not address contextual and system issues, most often fail. Promoting positive change in LTC homes requires requires a multilevel, systems approach. Objectives: Evaluate the effectiveness of the Feasible and Sustainable Culture Change Initiative (FASCCI) model for improving the provision of person-centred mealtime practices in a LTC home. Methods: A single-group, time series design was used to assess the impact of the FASCCI model for change on outcome measures across four time periods (pre-intervention, 2-month, 4-month and 6-month follow-up). Differences in scores from baseline were assessed utilizing Wilcoxon signed-rank tests. Interviews (n = 21) were also conducted to examine treatment fidelity and to ascertain the study participants’ perceptions of the process for making improvements using the FASCCI model. Findings: We observed increases in care staff’s capacity to consistently provide relational and person-centred care during mealtimes. Mealtime environment scores started increasing immediately following the intervention, with statistically significant improvements in all mealtime environment scales by six-months, including: the physical environment (W = 55.00, p = 0.008); social environment (W = 55.00, p = 0.008); relationship-centred care (W = 45.00, p = 0.014); and overall quality of dining environment (W = 55.00, p = 0.010). Analysis of data from qualitative interviews demonstrated that use of the FASCCI model resulted in improved team leadership, communication, and collaborative decision-making. Limitations: Generalizability is limited due to the small sample size and use of convenience sampling methods. Implications: Outcomes indicate that the FASCCI model seems promising in its ability to improve PCC mealtime practices in LTC homes and is worthy of a larger scale study. The results further demonstrate the value of supportive team environments in quality dementia care

Intersections in rural long-term care: a comparative case study in Alberta

In this report, we outline the results of a comparative case study of long-term care (LTC) in rural Alberta.Ye

Nonpharmacological management of behavioral and psychological symptoms of dementia: what works, in what circumstances, and why?

Sherpa Romeo yellow journal. Open access article. Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0) appliesObjective: Behavioral and psychological symptoms of dementia (BPSD) refer to the often distressing, noncognitive symptoms of dementia. BPSD appear in up to 90% of persons with dementia and can cause serious complications. Reducing the use of antipsychotic medications to treat BPSD is an international priority. This review addresses the following questions: What nonpharmacological interventions work to manage BPSD? And, in what circumstances do they work and why? Method: A realist review was conducted to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases for empirical studies that reported a formal evaluation of nonpharmacological interventions to decrease BPSD. Results: Seventy-four articles met the inclusion criteria. Three mechanisms emerged as necessary for sustained effective outcomes: the caring environment, care skill development and maintenance, and individualization of care. We offer hypotheses about how different contexts account for the success, failure, or partial success of these mechanisms within the interventions. Discussion: Nonpharmacological interventions for BPSD should include consideration of both the physical and the social environment, ongoing education/training and support for care providers, and individualized approaches that promote self-determination and continued opportunities for meaning and purpose for persons with dementia

The influence of information exchange processes on the provision of person-centred care in residential care facilities

Purpose: The movement away from task-oriented care toward the consistent provision of person-centred care (i.e., care based on residents’ needs and preferences) is widely recognized as the goal of the residential care culture change movement. The purpose of this study was to explore why the attainment of this goal has remained elusive for many residential care facilities (RCFs), despite significant effort to alter practice. Methods: I conducted an institutional ethnography to explore the textually mediated work processes that influence the day-to-day work practices of front-line care staff in RCFs. The social organization of RCFs was explored through the observation of resident care attendants’ (RCAs') practices and the interaction of those practices with institutional texts. The data were derived from three RCFs and included 104 hours of naturalistic observation, 76 in-depth interviews, and document analysis. Results: Practical access to institutional texts containing care-related information was dependent on job classification. Regulated healthcare professionals (e.g., RNs) frequently accessed these texts to exchange information. Although RCAs provided 80% of the care to residents, in all sites studied, they lacked practical access to the institutional texts that contained important information relevant to the residents’ individualized care needs and preferences (e.g., assessments, care plans, social histories). The RCAs primarily received and shared information orally; however, the organizational systems in the facilities studied mandated the written exchange of information and did not formally support an oral exchange. Consequently, the oral exchange of care information was largely dependent upon the quality of the RCAs' working relationships with one another and especially with management. Implications: Access to detailed knowledge of residents’ needs and preferences is fundamental to the provision of person-centred care. The transfer of this knowledge to and between front-line care staff is dependent upon the quality of the relationships managers develop with and among RCAs. Initiatives aimed at building supportive and collaborative work teams are essential to the inclusion of RCAs in the care planning process and to the attainment of the goal of person-centred care.Graduate and Postdoctoral StudiesGraduat

Long-Term Care in Rural Alberta: Exploring Autonomy and Capacity for Action

Context: Since the 1990s, Alberta, Canada has seen considerable restructuring to health and long-term care (LTC) services. Most LTC research is conducted in urban centres. As a result, little is known about the effects that restructuring has had on rural LTC homes. Objective(s): In this article, we outline our findings related to autonomy and capacity for action in rural LTC homes. Method(s): We conducted a multi-site comparative case study. Using rapid ethnography, we conducted weeklong site visits at three rural LTC homes. This involved two types of data collection: semi-structured qualitative interviews and field observations. We used a feminist political economy lens to analyze the data. Findings: Our findings offer insights into how rural LTC staff are empowered to create change and/or constrained from doing so. We outline these findings at macro, meso, and micro levels of analysis and conclude that a combination of site-level and systemic factors contribute to a LTC home’s level of autonomy and capacity for action. Limitations: Our findings reflect experiences and observations at three LTC homes at three distinct points in time. Though the data provide rich descriptions, they do not provide an exhaustive account of the strengths and challenges of rural LTC. Implications: Community resources, local industries, and other socioeconomic and organizational factors contribute to a community’s response to LTC restructuring and their ability to make change and ruralize their LTC provision. These factors, and the heterogeneity of rural communities, should be taken into consideration during decision-making about rural health policy and service provision