Caring for Older People: A Shared Approach

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Christine Brown Wilson

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    Copyright

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    Dedication

    To Lesley Wade; my mentor and friend, whose first book on gerontology inspired me to start my journey with older people.

    About the Author

    Christine Brown Wilson is a Programme Director in the School of Nursing, Midwifery and Social Work, University of Manchester, United Kingdom. Christine's roles include managing and teaching on a post-registration undergraduate degree programme, research involving older people, including those with dementia, and supporting practice. Christine qualified as a Registered Nurse 30 years ago and has worked with older people in hospital, the community and long-term care. Christine is committed to improving care for older people, including those with dementia through education, research and practice development.

    Christine encourages students to use biographical approaches when assessing older people, including those with dementia, and involving older people in care decisions. Christine's initial research focused on relationships between older people, families and staff in long-term care, identifying what approaches to care provide the most positive experience. She has published widely on this subject. Christine is now working with care providers to develop services using these findings. Christine is also health care lead for an interdisciplinary team developing technology to enable older people and those with dementia to remain active in their community. She is particularly interested in how technology supports decision making by health care professionals.

    Christine is a member of the National Care Homes Research and Development Forum that provides a network across universities to support collaboration in research and practice development with a view to influencing the policy and research agenda in this area. Christine regularly peer reviews for academic journals and for the National Institute of Health Research Programme.

    Foreword

    A sea change is occurring in how we think about and what we expect from care homes. Across the world we have seen a growing discontent with the state of affairs in care homes and general recognition that we should expect and need to create something better. Easier said than done! It's not so easy to convert the rhetoric, or even a strong commitment, into the right actions.

    Good people with the best of intentions struggle to find ways to create a better space for people who live and work in care homes. Many do not accomplish what they set out to achieve. This leaves people who live in care homes with something less than they deserve (although unfortunately not often less than they expect). It also leaves the committed staff, trying to improve the situation, feeling frustrated. Nothing seems to work.

    It's easy to look at care homes we believe are not performing well and villainise the care staff, or the administration or the sector.… This simply adds to the sense of frustration for staff who have worked so hard and failed to achieve what they know is right. This does not give us a guide for improving things.

    So how does Christine Brown Wilson's book fit here? Dr. Brown Wilson has already contributed much to the field, offering us important insights into what really good care might look like. So what does this book add? Dr. Brown Wilson does several important things with this book. Let me start with the care staff. By carefully laying out the various perspectives that used to provide ‘really good care’, Dr. Brown Wilson allows us all to find ourselves, and to gain insight into both the sources and consequences of the perspective we hold. For some of us this might be uncomfortable, but the discomfort does not come from what Dr. Brown Wilson says about us. It comes from our own insights gained in reading this book. As any effective educator knows, helping someone come to their own insight is much more powerful and lasting than just telling them. Dr. Brown Wilson obviously uses her considerable experience as an educator to walk us up to a place where we can see for ourselves.

    She shows us how a particular path, even one often taken by highly committed and well-intentioned care workers, leads us to an end that we would not find satisfactory. She does this without inducing shame or raising questions about the values and motivation of people who find their efforts failing to achieve ‘really good care’. This is done gently, in a way that allows the reader to come slowly to a realization without feeling accused. Some readers will find their cherished notions of ‘really good care’ called into question, by demonstrating where they lead, but they will not feel that their efforts or their motives have been impugned.

    Dr. Brown Wilson uses vignettes and activities throughout the book to nudge people to examine where their values, assumptions and perspectives might be leading them. These are subtle but powerful strategies to engage the reader and continuously bring the discussions to a very practical level.

    Dr. Brown Wilson weaves the philosophical, empirical and practical together in a way that makes this book quite useful and engaging for researchers, educators and practitioners alike. Being clearly grounded in empirical research, informed throughout by a philosophy of respect for all involved, while offering many practical solutions, is indeed unusual. More often we find one of these three elements alone, leaving us, particularly those in practice, wondering what to do with a particular insight. Dr. Brown Wilson does not stop at insight. She takes us the next step, guiding us in how we might want to put the insight to work. The depth of practical guidance here makes this a very useful resource for people working in and overseeing care homes.

    The book is easy to read, engaging, practical and provokes us to reflect on what we are doing, how we are doing it and what we hope to achieve.

    Barbara Bowers PhD RN

    Helen Denne Schulte Professor

    Associate Dean for Research

    University of Wisconsin-Madison

    School of Nursing

    Preface

    I have worked with older people in the independent and statutory sectors in the United Kingdom (UK) for the past 25 years. In this time I have seen a very positive trend in seeing older people as individuals, promoting independence and taking into account the needs they identify and choices they make. As a student and newly qualified practitioner, I recognised the importance of care that did not exclusively focus on my professional goals but also incorporated what was important to the older person. Working in the homes of older people enabled me to recognise the importance of independence, inter-dependence and feelings of control for the older person as they experienced a health crisis. We worked together to identify goals that reflected their life aspirations, as well as the professional goals the service needed to provide. I began working in person-centred ways before we had the guidance of recent theoretical models and this experience maintains my enthusiasm and passion for ensuring that we maintain the focus on what is important for older people themselves.

    In the present day we are still seeing practice in the UK that falls below the minimum standards we would expect for older people. This is disappointing as much of this substandard practice resonates with findings from some of the early sociological research from the 1960s (Goffman, 1962; Townsend, 1962). Equally, we also know there are areas of very good practice that have improved over the past decade. We are now beginning to see some very positive reports from the care home sector with areas of very good practice (see My Home Life [http://www.myhomelife.org] for examples of this). Unfortunately, this has not been reflected as well in the acute sector with a number of reports outlining very poor care for older people (Abrahams, 2011). That is not to say there is not very good care in the acute sector, but research continues to find pressures of targets impacting on time, resulting in care for older people that often lacks dignity (Brooker et al., 2011; Patterson et al., 2011; Tadd et al., 2011). Areas of positive practice across sectors are often seen when there is leadership, good teamwork and continuity of care (Brown Wilson, 2009; Patterson et al., 2011).

    The content within this book draws on research I have undertaken in long term care environments (Brown Wilson, 2009; Brown Wilson and Davies, 2009; Brown Wilson et al., 2009b) incorporating the perspective of older people, families and staff. It became obvious to me as I spent time talking with older people, observing their interactions with each other, their environment and staff supporting them that older people are actively contributing towards their care in ways often not recognised by health and social care staff. Indeed, witnessing the communication style of many nurses, I recognised how we become desensitised to the important information being shared with us as we fail to see the relevance of stories older people share with us. While this might be understandable in the context of the many tasks nurses have to undertake, it means we miss vital information in supporting older people to live meaningful lives, and fulfil their aspirations. Subsequently, I have applied this research to my teaching practice with final year undergraduate nurses and found that many students are witnessing very task-directed practice in both the acute and community environments. However, by using some of the key tenets of my research, many were able to make a real difference to the day-to-day care of older people by being aware of the myths and stereotypes guiding practice with older people, by listening to the stories older people shared with them and then identifying how they might address not only the needs of older people, but also their aspirations. As health and social care practitioners, we do bring professional knowledge and expertise to the relationship when working with older people.

    The aim of this book is to provide a means of navigating through the many concepts that have emerged over the past decade related to working with older people, guiding you, the reader, in how these concepts might be put into practice. Although we can see many positive changes in environments caring for older people, there are also times when care for some of the most vulnerable in our society remains sadly lacking. This book provides a supportive approach to working with older people, reminding us of ways of working that sometimes seem so obvious. However, we know that when confronted with a hectic work environment, it is often the most fundamental aspects of working that get forgotten and result in poor or dehumanising approaches to care. This book is not intended to tell you what professional knowledge you need when working with older people – there are many excellent books on evidence-based practice to support you in this. What this book does is provide you with is a way of implementing your professional knowledge using the perspective of the older person, ensuring their goals in life are being met alongside the professional goals practitioners are tasked to deliver. Therefore, this book provides a step-by-step guide in how to work effectively with older people in changing health and social care contexts involving the older person and their families or supporters.

    This book seeks to consider how we as practitioners might adjust our practice to consider the needs and aspirations of the older people who need our support as they age. I work on the principle that we change practice one person at a time, starting with ourselves. There are suggestions for how we as individual practitioners might adjust the way we work at different times, enabling us to be more responsive rather than adopting a blanket approach when working with older people. Importantly, we consider how valuing the contribution older people and their families make to their care, might enable nurses in particular to (re)consider their role in bringing the voice of the older person to the decision-making process. This includes ideas for the development of leadership and teamwork that will facilitate teams working in more adaptable and flexible ways, ensuring the needs of older people are being met in ways that involve them in the decision-making process. This will enable us to manage complex care environments, to consider competing needs and still address what is important to the older person and their family.

    To achieve this, we need to address some fundamental questions that redirect the focus from ourselves as practitioners to those whom we are supporting:

    • How do older people see their health and how does this influence the decisions they make?
    • How does what has happened in an older person's life influence their approach to ageing?
    • How do we recognise the contribution made by an older person or their carers?
    • How might we include older people, families and their supporters in the decision-making process?
    • How do we identify what is significant in an older person's life at this point?
      • What are the important routines they wish to maintain and how might they be supported in this?
      • What are the important relationships in an older person's life and how might the service be impacting on these?

    These issues are not unique to this book and as such it should not be read in isolation from other texts that may address each of these issues in more depth. The uniqueness of this book lies in how the student is encouraged to address these issues with the older person as part of their everyday practice.

    The case studies throughout this book are derived from both research and practice. The approaches to care were developed from my research in long term care (Brown Wilson, 2007). This work has been published in a number of journals, which I refer to as appropriate throughout the book. There are also previously unpublished examples which are used from this research. Throughout this book I also draw on colleagues' research to demonstrate how the findings from my research in long term care are transferrable to other care environments. The application of many of the principles underpinning the approaches to care developed in my research has been undertaken by undergraduate students as they grapple with applying theory to everyday practice. These examples demonstrate how students have used the underpinning principles within this book to improve the care of older people. To achieve this, these students have valued the perspective of the older person and considered it to have equal merit to the professional perspective. This has meant the student has often had to suspend their professional perspective to hear the voice of the older person and in so doing has then had additional information to inform their professional perspective. The students who have contributed their work throughout this book demonstrate how it is possible to move beyond the immediate needs of the older person to consider their goals and aspirations as well. The examples used within this book all involve real people in real situations, although their identities have been changed, to demonstrate how it is often the simple things that can make a world of difference to an older person, their family and staff. They are designed to encourage you to think differently about the practice situations you find yourself in.

    Navigating This Book

    This book is divided into two parts. Part 1 considers the research that underpins different approaches to care and how recognition of the contribution of older people and their families might improve the experience of care. The chapters are arranged sequentially with an overview of the literature followed by an in-depth exploration of three approaches to care moving from a relatively limited participation with older people and families towards a more participatory approach that involves older people, families and staff in care decisions. The final chapter evaluates the evidence presented in previous chapters to consider how we might integrate the user perspective into quality assessment.

    Part 2 considers a range of practical strategies from research and practice that may support staff in adopting the different approaches to care described in the first part of the book. It begins with an outline of some of the popular myths and stereotypes held about older people that student nurses have observed in practice environments. The following chapters are arranged to consider strategies that primarily involve staff towards those that adopt a more participatory approach valuing the contribution of older people, families and staff.

    To support you, the reader, in navigating this book, each chapter has a similar format:

    • Graded learning outcomes take the student through the description of the content to how to examine and analyse the information, enabling them to develop personal strategies in implementing the information from each chapter.
    • Case studies from a range of practice environments show direct application to practice.
    • Activities support the student in applying the information within each chapter.
    • Final summary of key learning.
    • Suggestions for further reading.

    The references used throughout this text can be found at the back of the book.

    Finally, the term student is used loosely – you may be starting a career in health and social care, returning to study after years of health or social care experience, or involved in continuous professional development, and so there are times when I may use the terms student and practitioner interchangeably. Throughout this book, I consider the student as a developing practitioner, so any learning should then lead to actions as a practitioner. I hope you find this book useful.

    Christine Brown Wilson

    Acknowledgements

    This book would not have been possible without the contribution of older people, families and staff two supported me in my initial research in care homes. They gave their time and insights which provide many of the examples within this book. In my teaching, I often find the concept of successful ageing a difficult one to convey to students. I would like to thank my relative, Marjorie, for her unique insight into how an older person approaches successful ageing. She has proved an inspiration to both me and my students.

    Many of the students I teach grapple with the concepts in this book alongside the other demands of their course. In spite of many difficulties, these students have worked hard to apply the principles in sometimes less than understanding environments. I thank them for their contribution to the seminars and sharing their experience which I have tried to capture within this book. You have made a real difference to the lives of older people – you are the future for ensuring these principles become everyday practice – I have great faith in you.

    There have also been students who have supported me in communicating some of these principles in ways that have been accessible to their peers, contributing directly to this book. For this I am particularly grateful to: Faye Alexander, Kirsha Anderson, Sarah Bowers, Rachel Brown, Emma Buckley, Chantal Corneill, Dephine Genti, Rhona Johnson, Brenda Kabalira, Thea O'Doherty, Christopher Perry, and Louise Seaward.

    This work is based on my PhD for which I acknowledge the supervision and mentorship of Dr Sue Davies and Prof. Mike Nolan. However, the application of these principles across contexts would not have been possible without the support of colleagues who have generously provided me with the findings of their research, in particular Belinda Dewar and Philip Clissett.

    I have also been influenced by work undertaken in the USA by Professor Marilyn Rantz and her Quality Improvement Team based at the University of Missouri. I thank them for their welcome and hospitality. The discussions and visits enabled me to understand the US long term care system and how the principles within this book might be applied in the US context.

    Last but by no means least, I acknowledge my family – Terry my husband who supports me tirelessly in my work and whose skills in proofreading are invaluable, and my children, Amee and Leigh, who often provide a fresh perspective in our discussions of the issues faced by older people. I would not have been able to complete this book without your love and support, so thank you.


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