Well-being and expression of self in dementia: interactions in long-term wards and creative sessions

Fiona Kelly
University of Stirling

This is a multi-method ethnographic study, grounded in symbolic interactionism and social constructionism, which seeks to explore the social worlds of people with dementia in institutional long-term care. Carried out over six months, it uses non-participant observation, Dementia Care Mapping, video-recording, focused conversations and extensive fieldnotes to document types of interactions that fourteen people with dementia received in everyday ward life and during weekly creative sessions facilitated by occupational therapy (OT) staff. Using Kitwood’s (1997) work on person-centred care and Sabat’s (2001) work on selfhood (Selfs 1-3) it identifies their responses to such interactions in terms of their well or ill-being and expressions of Self.

The study shows that everyday staff interactions with participants, while sometimes positive, were more often limited in their potential for maintaining or increasing well-being. Sometimes staff interactions were abusive; causing participant ill-being. Participants expressed Selfs 1-3 verbally and visually, although some of these expressions were subtle, fleeting and fragile.

During creative sessions, OT staff engaged in sustained positive interactions, raising participant well-being and facilitating Self-expression; a fragile expression of Self could become a robust expression of Self, a past Self could be reclaimed and a desired Self co-constructed.

My findings suggest that, in their interactions during creative sessions, OT staff generally recognised and supported Self of participants, raising well-being. However, ward staff did not fully recognise and therefore could not support Self in their interactions with participants, resulting in participant ill-being. This is a crucial finding, which could partially explain the differences in interaction types I observed, and the corresponding differences in participant well-being and Self-expression.

This thesis argues for integrating the selfhood and person-centred approaches into an innovative staff-training programme, in order to bring about transformational change in practice. This might encourage care staff to reach out, recognise and respond to aspects of Self as they carry out care; promoting more positive ways of interacting with their patients, increasing patient well-being and fostering staff satisfaction.

Defining roles, relationships, boundaries and participation between older people and nurses within the home setting: an ethnographic study

Julie McGarry
University of Nottingham

This study explores the nature of relationships between nurses and older people within the home, from the perspectives of both nurses and older people. The impetus for undertaking this research arose from recognition of contemporary policy reforms which, alongside changing demography, suggest that older people will increasingly become principal recipients of care in the home. However, while earlier research had highlighted the issues that had historically pervaded health care provision for older people in acute settings, there was a paucity of comparable evidence regarding the particular situation of older people from within this specific context of care.

Social class dynamics in later life: a case study of class structuring and action among older persons in Malta

Marvin Formosa
University of Bristol

The aim of this dissertation was to conduct a critical investigation of the interface between social class and later life. Its objectives were to investigate the relationship between ‘later life’ and the established features of class structure, class formation, class consciousness, and class struggle (while remaining attentive to the gender dimension). Pierre Bourdieu’s contributions to class research and the life course perspective served as key reference points for the planning and carrying out of the study. The empirical process, which took Malta as its social setting, commenced by the carrying out of exploratory research (focus groups) to operationalise the concept of ‘class’. This was followed by a mixed-method procedure of data collection that employed structured interviews and semi-structured life histories in a sequential manner. In the spirit of the critical paradigm, the extensive and intensive analyses of empirical research were allocated heuristic and explanatory status respectively.

While the cluster analysis of extensive data located four classes, analysis of intensive data located a further number of factions. Classes were labelled ‘conservative’, ‘grey-collar’, ‘middle’, and ‘dominant’. Data revealed that older persons experienced their class identities in ambiguous ways, arising from their daily involvement in various cultural practices. This study also recorded an ascendancy of individualised class action as most older persons distanced themselves from ‘collective’ forms of class struggle. Moreover, results showed that the possibility of class mobility does not end following retirement since retirees continued to experience either downward or upward class mobility. This dissertation therefore showed that class remains a pervasive element in later life, whilst also demonstrating how the study of class structuring and action in later life necessitates a focus on the interrelation between ‘class’ and ‘age’ relations.

Muscle Function and Functional Ability in Resistance Trained Older Adults

Tim Henwood
School of Human Movement Studies and the Australasian Centre on Ageing
University of Queensland

Resistance training commenced late in life has proven to be a safe and effective means of increasing muscle function and functional ability in older adults. While most research has investigated strength training, it has recently been suggested that muscle power (the product of force and the rate at which force is produced) training may be more important given that power declines at a greater rate than strength with age and that muscle power is significantly associated with activities of daily living.

Interventions that have used high-velocity varied resistance protocols in older adults report substantial increases in muscle power. However, no studies are currently available investigating whether this form of training produces greater physiological benefit than that of a conventional strength or functional training program. Furthermore, the impact of these training regimes on a subsequent period of activity cessation has important implications for individuals foreseeing a period of enforced inactivity. While research suggests a significant loss in muscle strength and functional performance following detraining, to date, no data are available for muscle power.

A further consideration is the effect of increased physical activity on the quality of life of the older individual. While research has failed to show an association in community-dwelling older adults commencing exercise, the appropriateness of the instruments employed to measure quality of life is questionable. To address these research shortcomings, 3 resistance-based interventions and the analysis of a new quality of life instrument were undertaken using community-dwelling older adults: Study 1 compared 24-weeks of conventional muscle strength (ST) and high-velocity varied resistance muscle power (HV) training to a group of non-training controls (CO), Study 2 investigated a subsequent 24-week period of detraining followed by 12 weeks retraining in the ST and HV groups, and Study 3 compared the short-term (8 weeks) outcomes for the ST, HV and CO group to a combined (CB) training group who undertook once weekly high-velocity varied resistance and once weekly functional training. In addition, a new quality of life questionnaire, the University of Queensland Quality of Life instrument (UQQoL), informed by focus groups among older adults, was designed and validated (Study 4). During training and retraining subjects trained twice weekly, which consisted of 3 sets of 8 repetitions for 3 upper- and 3 lower-body exercises. For Studies 1 and 2, muscle function (dynamic and isometric muscle strength, muscle power, muscle endurance and movement velocity), functional performance (battery of 8 tests), body composition, bone mineral density, and quality of life were assessed, while for Study 3, dynamic muscle strength, muscle endurance, and functional performance were assessed. Sixty-seven individuals (65 – 84 years) were randomised to 3 groups (HV: n = 23, ST: n = 22 and CO: n = 22). For Study 3, following the completion of the primary training study, members of the CO group undertook CB training with results compared to the short-term outcomes from Study 1. For Study 4, the UQQoL questionnaire was established following a comprehensive reliability and validity process, and trialled during Study 1. Twenty four weeks training (Study 1) significantly and similarly increased muscle power (50.5 ± 4.1% and 33.8 ± 3.8%) and muscle strength (51.0 ± 9.0% and 48.3 ± 6.8%) in the HV and ST groups, respectively, and improved selected functional performance tasks in training groups when compared to controls (p < 0.05).

Following detraining (Study 2), similar declines in muscle power and muscle strength were observed for both groups (power, 17.8 ± 1.8% and 15.5 ± 2.2%; strength, 17.1 ± 2.2% and 16.5 ± 1.8%, HV and ST, respectively), with comparable accrual following retraining. No significant changes in functional performance were observed in Study 2. Short-term training (Study 3) resulted in muscle strength increases of 22.0 ± 12.5%, 21.7 ± 11.0% and 26.1 ± 14.4% in HV, ST and CB, respectively, compared to CO (–1.8 ± 7.2%) (p < 0.001). Between group analysis revealed only the HV group had greater chair rise ability (p = 0.01) than the CO group. Within groups, the HV group significantly improved in stair climbing and chair rise ability (p = 0.001), while CB improved their fast 6-m walk (p = 0.003) and ST improved in the functional reach task (p < 0.001). No significant training group differences emerged during Studies 1, 2 or 3. The UQQoL displayed good convergent validity and retest reliability among the target population with exercising older adults displaying an improvement in quality of life following 24 weeks of training.

These studies indicate that significant and comparable increases in muscle function and functional ability can be achieved by older adults undertaking resistance training using varied protocols. In addition, while declines in strength and power result following detraining, high-intensity training undertaken prior to training cessation may help preserve functional status in older adults expecting an extended period of inactivity. These studies reinforce the effectiveness of resistance training to aid in prolonging functional well-being in the older population.

Utilising an ethnographic approach, incorporating participant observation and semi-structured interviews with nurses and older patients (aged 65 years and over), the nature of the care relationship within the home setting was explored. Thirteen older patients who were receiving nursing care within the home and sixteen community nurses within one Primary Care Trust in the East Midlands UK took part in the study. Data were collected over a period of one year. Relevant documentation, for example, local district nursing philosophy was also used as additional sources of information.

Three themes emerged from the data: the location of care; the nature of nurse-patient relationships; and the meaning of health and illness. These offer an account of the ways in which roles and relationships are constructed, negotiated and experienced by nurses and older people within the home and demonstrate that relationships between nurses and older people in this environment are multi-faceted. They also illuminate the pivotal position of the concept of ‘boundaries’ and boundary construction within relationships from a number of perspectives.

In order to explore and examine nurses and older patients experiences of care within the home, the discussion of the findings is set within the context of salient theoretical perspectives surrounding boundary maintenance, the location of care and the nature of nurse-patient relationships, and more particularly, person-centred care. The discussion is developed in this way in order to examine how key points arising from the present research fit within the context of the existing literature.

Finally, this study makes a wider contribution to our knowledge of the complexity of nurse-older patient relationships within the home. It does this by illuminating the centrality of relationships between nurses and older people, in defining the experiences and perceptions of both groups, of the quality of care overall. This analysis therefore challenges traditional notions of professional boundaries and highlights the realities of negotiation and boundary blurring that form part of everyday practice. It also illuminates the day to day realities of district nursing practice and the multiple dimensions which underpin how care is provided and experienced in the home. Moreover, the core qualities that underpin the receipt of care within the home, for older people, have been clearly illuminated. It is therefore argued that, as the location of care continues to move closer to home, it is crucial that the implicit qualities that are valued within nurse-patient relationships within this context of care are recognised and made more explicit at both the organisational and policy level.