The challenge of the medical setting for the clinical specialist in psychiatric nursing

The purpose of sharing these ideas about the role of the psychiatric clinical specialist in the medical setting has been threefold: first, to stimulate the interest of others by communicating the needs for and the value of such a role in improving health care; secondly, to convey the variety of potential opportunities available in the role; and third, to share some ideas about specific activities which can be pursued in such a role. The clinical specialist who chooses to work in the medical setting will discover opportunities to develop creativeness, to explore innovative ideas, and to utilize the variety of one's personal resources and past learning experiences. It affords one with opportunities to serve as a change agent, to influence the quality of patient care, and to stimulate the growth of other nurses. It allows for on-going contact and exchange with other professional groups comprising the health care team, and finally, it provides the nurses with a high level of autonomy and challenge in defining their own roles.     

Training the Future Workforce: Social Workers in Integrated Health Care Settings

The current study explored social work skills and competencies required for work on integrated health care teams. Semi-structured, qualitative individual interviews were conducted with social workers employed in integrated health care settings. Key themes emerged around existing social work strengths, further training that is needed for this work, and fundamental skills for effective team-based collaboration. Incorporation of content, such as the social work role in integrated health care settings, advocacy in team-based treatment delivery, and incorporating medical knowledge into the social work curriculum are key to strengthening the future workforce. Education strategies can include not only infusion of integrated health care material into existing courses but also micro- and macro-specific elective courses and a range of interprofessional learning opportunities.     

Towards Customized Deliberations

ABSTRACT

The profession of social work has important contributions to make in the rapidly developing dialog about medical care decision making and to the evolution of hospitals as systems that engage with people as patients, for whom illnesses create increased vulnerability (Gruber, 1998). Professional ethics clearly states that the individual professional social worker has a responsibility to influence processes involving vulnerable populations. Articulating social work's responsibility and potential contributions in the area of medical care decision making begins with an application of social work's mission and values, and then continues with consideration of the profession's evolving role in hospitals. Pertinent aspects of the health care industry, including current models for continuum of care and for provider-patient relationships, are discussed in terms of opportunities to modify the models used to guide interactions with patients. Finally, the impact of a growing number of distinct treatment options is also considered. The objective of the article is to offer social workers in health care settings a conceptual framework for considering professional ethical obligations and for participating in the contemporary dialog regarding medical care decision-making.     

Evidence-based medicine, clinical uncertainty, and learning to doctor

For the past two decades, evidence-based medicine (EBM), or the reliance on current scientific evidence to reach medical decisions, has been embraced as a new paradigm to standardize clinical care. Drawing from in-depth interviews with seventeen pediatric residents in two residency programs, we evaluate the extent to which the medical sociology scholarship on uncertainty analytically elucidates the recent influx of EBM during residency training. Our findings suggest that residents interpret EBM in varying ways to match their work practices: "Librarians" consult the literature while "researchers" evaluate it critically. For both groups, EBM might generate new uncertainties due to the increased reliance on information technologies and epidemiology. Whether EBM reduces uncertainty depends upon the residents' understanding of standardized knowledge and consequent incorporation of EBM in their clinical practice. Contrary to the predictions of some sociologists, EBM does not lead to a diminishment of humanitarian values in medical care. Nor does EBM lead to a science-based meritocracy on the patient ward, as claimed by some EBM advocates. Our conceptual updating of uncertainty emphasizes the continuous management of uncertainty during the medical socialization process. We argue that managing uncertainty develops along with what we term evidence-based clinical judgment.     

On the edge: Balancing health, participation, and autonomy to maintain active independent living in two retirement facilities

This study examines how independent living residents in Continuing Care Retirement Communities (CCRCs) work to maintain a healthy, active community. Specifically, this paper elucidates how independent living residents, who have high status in CCRCs but also face transitions to more advanced care, manage their daily lives to build a positive sense of community against the backdrop of potential health and social declines. The researcher supplemented four years of observation in one CCRC and two years of observation in another with qualitative interviews with thirty residents from both facilities. Results indicated that shared sentiments contrasting the active social world in independent living with other living units, norms of mutual support balanced with autonomy, social participation as a source of belonging (or isolation), and definitions of deviance surrounding functional health and manners framed residents' understandings of daily life by reaffirming independent living residents' privileged status in each facility.     

The Middle Years of the Decade Publication Project

This article reports the results of a qualitative study of the professional identities, roles, and relationships of a variety of geriatric case managers located in nine demonstration sites around the United States. Beginning with an overview of social work and nursing roles in health care settings, the authors provide background on the study and its methods, followed by results that highlight the voices of persons interviewed. They conclude with implications for social work education in five areas: articulating social work's great tradition, developing career opportunities, building alliances with students and educators in other professional schools, engaging in ongoing faculty development, and infusing the social work curriculum with geriatric content.     

Relational Autonomy in Assisted Living: A Focus on Diverse Care Settings for Older Adults

Consistent with Western cultural values, the traditional liberal theory of autonomy, which places emphasis on self-determination, liberty of choice, and freedom from interference by others, has been a leading principle in health care discourse for several decades. In context to aging, chronic illness, disability, and long-term care, increasingly there has been a call for a relational conception of autonomy that acknowledges issues of dependency, interdependence, and care relationships. Although autonomy is a core philosophy of assisted living (AL) and a growing number of studies focus on this issue, theory development in this area is lagging and little research has considered race, class, or cultural differences, despite the growing diversity of AL. We present a conceptual model of autonomy in AL based on over a decade of research conducted in diverse facility settings. This relational model provides an important conceptual lens for understanding the dynamic linkages between varieties of factors at multiple levels of social structure that shape residents' ability to maintain a sense of autonomy in this often socially challenging care environment. Social and institutional change, which is ongoing, as well as the multiple and ever-changing cultural contexts within which residents are embedded, are important factors that shape residents' experiences over time and impact resident-facility fit and residents' ability to age in place.     

Advancing social inclusion in the neighbourhood for people with an intellectual disability: an exploration of the literature

The shift from segregated facilities to community settings did not automatically lead to social inclusion for people with an intellectual disability (ID). Policies are increasingly decentralized but little is known about the factors that are important to realize social inclusion in the neighbourhood. This literature study identifies five domains barriers and facilitators for social inclusion in the neighbourhood: individual characteristics, informal network, professional care, neighbourhood characteristics, and government policies. The findings suggest that social inclusion in the neighbourhood is a dynamic process that shows a series of complex interactions between environmental factors and personal characteristics to provide opportunities for people with an ID. It is recommended to include the perspectives of people with an ID and other neighbourhood residents in future research on social inclusion. Specific attention is needed for the role of neighbourhood social capital in achieving social inclusion in the neighbourhood.     

Sensitizing nursing home staff to residents' psychosocial needs

Most of the direct care of nursing home residents is provided by nursing aides. Aides generally have had limited training and experience working with the frail elderly and may not be attuned to residents' psychosocial needs. This can result in aides working at cross purposes with the social worker, producing a system that is counterproductive. This paper describes a situation where inservice training was utilized to help aides gain a greater understanding of the residents in their care. Advantages of using in-service are discussed, potential pitfalls are considered, and illustrations of in-service training techniques are presented.     

Meeting communication needs: topics of talk in the nursing home

Nursing home residents primarily rely on staff for communication and interpersonal relationships. Challenged by staffing shortages and increasingly complex care, staff who provide the most communication with residents lack awareness and skills to effectively communicate with older adults. This study, a secondary analysis of staff-resident interactions from one nursing home, explores communication topics and the effects of an intervention. Staff from one unit were recorded during 2 hours of caregiving to provide a representative sample of their communication with residents. Staff then attended an educational program targeting improved awareness of communication needs and reducing "elderspeak". Recording was repeated post-intervention. Baseline conversations focused on activities of daily living (ADLs), personal-social, technical care, and health assessment. Post-intervention ADL talk decreased in staff-resident interactions, while personal-social topics increased. These findings suggest that residents' limited opportunities for communication with staff are primarily focused on care tasks. With increased communication awareness, staff can learn to modify conversational topics to better meet older adults' psychosocial needs.     

Healthcare Use in the Heartland: How Health Care Selection Varies Between Rural,Retirement‐Age Migrants and Long‐Term Residents

One increasingly important problem affecting rural health care selection is the tendency of older residents to bypass local health care providers. This research investigates how the effects of community characteristics and attachment on health care bypass behavior vary between rural retirement‐age migrants and retirement‐age long‐term residents. Non‐health‐related behaviors, such as purchasing goods and services outside one's community during a health care trip, that is, “outshopping,” could influence bypass if individuals combine trips for their medical care with other consumer needs. Basing our work on the outshopping theory, we argue that bypass behavior is one facet of consumer consumption patterns for both rural retirement‐age migrants and long‐term residents. In addition, dissatisfaction with local health care and services like shopping can “push” rural residents to bypass local health care and travel greater distances for primary health care. We further contend that strong community attachment has an opposite “pull” effect that can help to negate the push of outshopping and reduce the likelihood of bypass. Our results reveal retirement‐age migrants are significantly more likely to bypass local primary health care providers than retirement‐age long‐term residents. Furthermore, our analysis bridges the rural health care and retirement community development literature to suggest that outshopping theory can now be applied to rural primary health care bypass behavior.     

Local Identity, Cultural Commodities, and Development in Rural Japan: The Potential as Viewed by Cultural Producers and Local Residents

Abstract:  This paper considers the development potential of rural and highly peripheral areas of Japan, focusing on local factors of development, together with local identity and cultural commodities, as these are incorporated into what has been called the culture economy. Based on a survey of informed local residents and another of local cultural commodities producers, the paper alludes to what constitutes a culture economy for rural settings and identifies several key aspects related to the process of such a cultural commodities-based approach to development. While confirming the importance of identity and cultural commodities in the local development profile of rural settings, the paper sets the groundwork for further research concerning the complex process for how such development can be achieved. The main themes identified for further research include both the nature and role of residents' solidarity together with the combinative nature of government support and local entrepreneurship in the local culture economy on the one hand, and the character of the advertising and media representation by which cultural commodities are created and maintained on the other.     

Health care,social care or both? A qualitative explorative study of different focuses in long-term care of older people in France,Portugal and Sweden

Challenges with an ageing population are increasingly becoming a reality in the Western world. Since cognitive impairment increases with age, we can expect an increasing number of older people in need of care. The aim of this article is to describe, analyse and compare different focuses on care of older people with dementia, using examples from France, Portugal and Sweden. The questions are principally focused on the participants’ view about their tasks, the organisation of work, the professional role and cooperation with other professions. Everyday care was studied through observations and participant observations and the staff's opinion was explored by means of interviews. Twenty-two care settings for older people were included. The findings showed that France provided mainly ‘health care’, Sweden ‘social care’ and Portugal an integrated ‘health care and social care’. In a comparative perspective the Portuguese general care of older people, which focuses on integration of health care, social care and social work, also seems to provide care for older people suffering from dementia which best corresponds to the previously developed group living model.     

The art and science of teamwork: enacting a transdisciplinary approach in work rehabilitation

Teamwork, collaboration and interprofessional care are becoming the new standard in health care, and service delivery in work practice is no exception. Most rehabilitation professionals believe that they intuitively know how to work collaboratively with others such as workers, employers, insurers and other professionals. However, little information is available that can assist rehabilitation professionals in enacting authentic transdisciplinary approaches in work practice contexts. A qualitative study was designed using a grounded theory approach, comprised of observations and interviews, to understand the social processes among team members in enacting a transdisciplinary approach in a work rehabilitation clinic. Findings suggest that team members consciously attended to a team approach through nurturing consensus, nurturing professional synergy, and nurturing a learning culture. These processes enabled this team to work in concert with clients who had chronic disabilities in achieving solution focused goals for returning to work and improving functioning. Implications for achieving greater collaborative synergies among stakeholders in return to work settings and in the training of new rehabilitation professionals are explored.     

Identifying the barriers and challenges to voting by residents in nursing homes and assisted living settings

To ascertain the need for and to inform development of guidelines for voting in long-term care settings, we conducted a telephone survey of Philadelphia nursing (n = 31) and assisted living (n = 20) settings following the 2003 election. Substantial variability existed in procedures used for registration and voting, in staff attitudes, and in the estimated proportion of residents who voted (29%+/-28, range 0-100%). Residents who wanted to vote were unable to do so at nearly one-third of sites, largely due to procedural problems. Nearly two-thirds of facilities indicated they assessed residents' voting capacity before the election. However, methods differed and may have disenfranchised residents who were actually competent to vote. Current procedures in many facilities fail to protect voting rights. These data suggest that rights might be better protected if election officials took charge of registration, filing absentee ballot requests, ballot completion, and trained LTC facility staff on voters' rights and reasonable accommodations.     

Mental Illness in Assisted Living: Challenges for Quality of Life and Care

ABSTRACT

An unknown number of mentally ill elders in the United States receive care in assisted living, along with persons facing physical or cognitive challenges. While dementia is familiar in assisted living, our data indicate that neither staff nor residents are prepared to work or live with the mentally ill. Challenges are created for professionals, since these residents bring diverse needs. Daily interresident interactions are also disrupted or stressful. Qualitative data describe the impacts on quality of resident life as well as care and management dilemmas identified within five assisted-living settings having varying presence of mental illness among residents.     

Total Immersion: Using Group Care Placements to Maximise Practice Learning

This paper presents findings from a survey of students' views on the experience of undertaking assessed placements in group care settings as part of their qualifying social work training. Respondents are positive and enthusiastic about the available learning opportunities in these settings, especially in terms of the possibilities for close involvement with service users and for learning about ‘real social work’. They emphasise the value of support from both on‐site supervisors and off‐site practice teachers, and reflect on the demands which such placements make in terms of students' personal resourcefulness in ambiguous role sets. The paper also offers advice for students, tutors and practice teachers on a range of issues involved in the planning of placements in group care settings, including comments on anti‐oppressive practice and on the use of reflective journals by students.     

The family's role in person-centered care: practice considerations

Effective implementation of person-centered care requires a shared understanding and commitment to make it a reality by administrative personnel, direct care providers, and residents and their family members. Long-term care facilities must seek ways to engage residents' families in person-centered care through its training, policies, care planning, and documentation. Doing so may require revisions to policies and work practices, and ongoing leadership efforts to maintain this care framework within the realities of staff turnover and regulatory requirements. Developing protocols and procedures that facilitate family members' communication with staff and build consensus and shared values will result in a system that represents and honors the unique perspectives, values, and needs of each resident receiving care. It is important for facility leadership to set the tone for acknowledging the importance of family involvement in person-centered care by modeling acceptance of concerns and criticisms as valid and by acknowledging that direct care providers, residents, and their family members have a voice in care decisions. Such an approach has the greatest chance of success in promoting person-centered care and the shared values necessary to ensure its successful implementation.     

Treatment of late-life mental disorders in primary care: we can do a better job

Health care services provided to older adults today are not as effective as they should be. The quality of care for late-life mental disorders often falls short of desired standards. The growth of the elderly population makes it imperative for the health care system to address late-life mental disorders more effectively. Intervention strategies based in primary care settings show the most promise, but effectiveness will depend on solving the geriatric psychiatry workforce crisis. Collaborative care is one promising model for improving geriatric mental health care delivery in primary care. Diffusion of collaborative care into the health care system and integrating geriatric psychiatry into other models such as geriatric medical homes will require redesign of the organization and financing of primary care and psychiatry to overcome current barriers. Public policy should reflect the essential role of psychiatry in geriatrics and promote the integration of geriatric psychiatry with primary care.     

Potential for the Abuse of Medication for the Elderly in Residential and Nursing Homes in the UK

ABSTRACT

Abuse of the medication prescribed to the elderly living in long-stay care homes may be perpetrated by a minority of unscrupulous doctors, pharmacists, or home staff caring for the residents. Disorganised practices and homes, poor communications, and sloppy professional practices may create opportunities for over-dosing, errors, fraud, or theft. This article describes the circumstances leading to the potential abuse of elderly residents' medication, and the measures that may be taken to avoid or minimise such abuse from occurring.