Cheryl Holman

The experience of living at home with frailty in old age: A psychosocial qualitative study

BACKGROUND With enhanced longevity, many people in late old age find themselves frail and living at home, often alone. Whilst conceptualisations vary, frailty is often used in clinical practice as a directional term, to refer to older people at particular risk of adverse health outcomes and to organise care. Investigation of the experience of being frail is a complementary and necessary addition to international research endeavours clearly to define, predict and measure frailty. Currently, there is little empirical work exploring how people over time manage being frail. OBJECTIVE The study aimed to understand the experience over time of home-dwelling older people deemed frail, in order to enhance the evidence base for person-centred approaches to frail elder care. DESIGN The study design combined psychosocial narrative approaches and psycho-dynamically informed observation. Data on the experience of 15 frail older people were collected by visiting them up to four times over 17 months. These data were analyzed using psychosocial analytical methods that combined case based in-depth staged analysis of narratives with psycho-dynamically informed interpretations of observational data. SETTING The study was carried out in the homes of the participants; all lived in a socio-economically diverse area of inner London. PARTICIPANTS 15 participants were purposively selected for living at home, being aged 85 or older and regarded as frail by a clinical multi-disciplinary intermediate care team. RESULTS The findings challenge the negative terms in which frailty in older age is viewed in the predominant models. Rather, frailty is understood in terms of potential capacity - a state of imbalance in which people experience accumulated losses whilst working to sustain and perhaps create new connections. CONCLUSION This study suggests that holding together loss and creativity is the ordinary, but nonetheless remarkable, experience of frail older people. For frail older people, the presence of others to engage with their stories, to recognise and value the daily rituals that anchor their experience and to facilitate creative connections is vital if they are to retain capacity and quality of life whilst being frail.

Becoming connected, being caring

This paper highlights perspectives on action research in education, health and social care and was originally presented as a keynote at the International Practitioner Research Conference and Collaborative Action Research Conference in 2005. The paper links with the other conference keynote given by Stephen Kemmis, co‐author of Becoming Critical. It reflects on the importance of Being Caring in action research in the context of health and social care; particularly in relation to emotionally supporting practitioners to improve their practice in settings which do not always welcome more emancipatory or critical approaches often used in education. The paper begins by exploring the nature of practitioner research and action research in health and social care and its links with quality. It argues that health and social care professionals have often drawn their methodological understanding from the literature written by colleagues in education. This literature tends to support critical and emancipatory forms of action research, which health and social care professionals have tended to adopt in an uncritical manner. Reflecting on some of the contextual constraints in health and social care, it argues that many of these factors are beyond the control of individual practitioners and suggests a need to focus on the neglected area of emotions, in addition to, contextual issues. To illustrate the usefulness of this approach an example of psychodynamically informed action research is given. The paper concludes that in the quest to be critical, practitioner researchers/action researchers in education, health and social care may be ignoring the emotional contexts in which they work. It suggests that being caring may be the key to being critical.

The Complexity of Loss in Continuing Care Institutions for Older People: A Review of the Literature

This article analyzes the findings of a literature review undertaken on loss in continuing care institutions. It suggests that research undertaken in continuing care institutions, such as care homes, ignores the complexity and multiplicity of loss, depending on the methodological approach taken (e.g., qualitative field methods, survey research and intervention studies). It argues that different methodological approaches fragment and hide some aspect of loss in these settings. For instance, some methods capture the individual emotional component, while others focus solely on the social dynamic. This fragmentation and hiding of aspects of loss makes research findings of limited value to those working in practice. The article concludes that future studies need to be aware of these tendencies, in order to uncover new meanings of loss more appropriate to the continuing care setting.

PSYCHOANALYTICALLY INFORMED RESEARCH IN AN NHS CONTINUING CARE UNIT FOR OLDER PEOPLE: EXPLORING AND DEVELOPING STAFF'S WORK WITH COMPLEX LOSS AND GRIEF

There are studies about the emotional and social aspects of loss and grief in continuing care environments such as care homes and hospital wards, but researchers have tended to focus on either the cultural aspect of the organisation or the emotional response of individuals [Holman, C., Meyer, J. & Cotter, A. (2004) ‘The complexity of loss in continuing care institutions for older people: a review of the literature’, Illness, Crisis and Loss, vol. 12, no. 1, pp. 38–51]. This splitting in the body of knowledge misses the opportunity to examine the link between the personal and the broader public domain [Williams, S. J. & Bendelow, G. (1996) ‘Emotions, health and illness: the “missing link” in medical sociology?’, in Health and the Sociology of Emotions, eds V. James & J. Gabe, Blackwell Publications Ltd, Oxford]. This paper concerns the methodology and initial findings from a psychoanalytically informed research study. It was aimed deliberately at exploring the juncture between the psychological and social domains that care staff have to negotiate in order to provide care related to loss and grief in an NHS continuing care ward. The method draws heavily on the Tavistock approach to learning about emotions [Rustin, M. (2003) ‘Learning about emotions: the Tavistock approach’, European Journal of Psychotherapy, Counselling and Health, vol. 6, no. 3, pp. 187–208] but also adopts participant observation methods rooted in the ethnographic tradition [Fielding, N. (2001) ‘Ethnography’, in Researching Social Life, 2nd edn, ed. N. Gilbert, Sage Publications, London]. The study identifies the emotional demand of caring for people experiencing loss and grief in a continuing care unit and the development of a reflective group that supported practice developments in meeting these tasks. The paper will argue that research that develops an understanding of social practices underpinned by psychoanalytic perspectives can inform development in areas where staff are expected to cope with high levels of anxiety and stress.

Establishing a community of practice for dementia champions (innovative practice)

This discussion paper considers the currently evolving roles of dementia champions and describes an initiative designed to support their activities. The aim of this initiative was to establish a county-wide group that has a shared group identity and sufficient critical mass that is able to identify and implement dementia training and development needs for the health and social care workforce. The approach used to achieve this aim was a Dementia Champion Community of Practice Project, which involved dementia leads in various NHS Trusts. Whilst this approach might be effective at practitioner level, the Dementia Champion Community of Practice Project experience suggests that if such initiatives are to be sustainable they need to be strategically placed within networks that can bring together service providers, educators and commissioners.

Moving from victim blaming to an appreciative inquiry : exploring quality of life in care homes

This paper highlights the need for researchers to work across disciplinary boundaries in order to capture the complexity that care practitioners have to engage with everyday in care home settings. Drawing on findings from a literature review on the complexity of loss in continuing care institutions for older people, the case is made for less victim blaming and more appreciative approaches to research. The way this thinking informed the development of a further literature review on quality of life in care homes (My Home Life) is discussed. Findings from this second study are shared by illustrating key messages with quotes from older residents, relatives and staff living, visiting and working in care homes. These best practice messages focus on: transition into a care home; working to help residents maintain their identity; creating community within care homes; shared decision‐making; health and health services; end‐of‐life care; keeping the workforce fit for purpose, and promoting positive culture. The importance of collaborative working in both research and practice is discussed. The paper is likely to be of interest to all those concerned with improving and developing evidence‐based practice in the care home sector, including users and service providers, managers, commissioners and inspectors, policy‐makers, researchers and teachers.

Spouses with partners with dementia living in institutional care develop visiting routines that help to maintain the spousal relationship

Commentary on: Forsund LH, Kiik R, Skovdahl K, et al. Constructing togetherness throughout the phases of dementia: a qualitative study exploring how spouses maintain relationships with partners with dementia who live in institutional care. J Clin Nurs 2016;25:3010–25.[OpenUrl][1] People with dementia may be cared for in institutional settings. This can lead to separation from a partner that may have involved love and emotional and practical care. This study by Forsund et al explored the experiences of 15 spouses in Norway whose partners had dementia and were living in institutional care settings. The … [1]: {openurl}?query=rft.jtitle%253DJ%2BClin%2BNurs%26rft.volume%253D25%26rft.spage%253D3010%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx

Advancing knowledge on practice change : Linking facilitation to the senses framework

AIMS AND OBJECTIVES To explore the facilitating factors that enabled staff on a rehabilitation ward for older people engage in change activities. BACKGROUND The importance of facilitation in practice change is widely acknowledged; however, little nursing research has taken place in relation to its nature. Following identification in the early phases of an action research study that learned helplessness states and the use of socially structured defence techniques were preventing staff on a rehabilitation ward for older people from engaging in practice development, some change was achieved. What facilitated this to take place needed to be explored. DESIGN An action research approach was used. METHODS Data gained from 13 in-depth interviews with staff and managers together with three years of researcher field notes were analysed using thematic analysis. RESULTS The continuous presence and neutrality of the researcher who worked together with staff on their issues of concern using a flexible ward-based approach, combined with giving staff the opportunity to explore what it was like for them working in this area, were considered key in helping staff to engage with change. CONCLUSIONS Analysis of findings suggests that the senses framework presents a theoretical approach to facilitation that can help staff move out of learned helplessness states and reduce the need for the use of socially structured defence techniques. RELEVANCE TO CLINICAL PRACTICE This study identifies a facilitation approach that enabled staff to engage with practice change. Although carried out in the UK, its findings have wider relevance through the application of a theoretical perspective for practice change facilitation that has not before been considered in this literature, and which is likely to be of interest to those involved in practice change internationally.