Scales, Kezia
(2014)
Doing what makes sense: locating knowledge about person-centred care in the everyday logics of long-term care.
PhD thesis, University of Nottingham.
Abstract
Addressing criticisms of the routine-driven, task-oriented, depersonalising nature of conventional services, and reflecting a broader trend across health and social care, person-centred care has become the watchword for quality in long-term care for older people in recent years. Person-centred care requires recognising the unique personhood of each individual regardless of their physical or mental capacity. Efforts to realise this approach depend largely on the non-professional nursing staff who deliver the majority of direct care in this context. However, little is known about how new knowledge, including ideas and evidence about person-centred care, translates into the daily practices of this cadre of staff, who have little formal training, low job status, and limited access to traditional forms of research dissemination and knowledge exchange.
Building on the existing knowledge-translation literature, therefore, the aim of this study was to explore the mechanisms of knowledge translation about person-centred care among care assistants in long-term care. The objectives were to examine how these staff develop their understanding of person-centred care; identify the personal and contextual factors involved; and explore what can be learned about person-centred care from their current practices. The study used ethnographic methods, including 500 hours of participant observation, in-depth interviews, and document analysis, to conduct case studies of two private nursing homes located in the East Midlands and the north-eastern United States. Without claiming to demonstrate causality, extending the research across two policy settings did facilitate the identification of pertinent issues within and beyond each individual facility. Data analysis was informed by practice theory, which provided an alternative to the individualist assumptions which characterise popular representations of long-term care, on the one hand, and, on the other, structural explanations that renounce individual agency altogether.
From this theoretical perspective, drawing in particular on Bourdieu‘s theory of practical logic and the neo-institutional concept of institutional logics, this study identified how the interconnection of particular practices within each setting produced different situated understandings and implementation of person-centred care. A key finding was that care assistants' individualised knowledge about each resident, obtained through their direct daily care, represented an important form of symbolic capital in this field. Their willingness or reluctance to share such knowledge, consequently, corresponded to the extent to which other practices, including communication and teamwork, supported or threatened this limited source of power. The second, related finding was that care assistants derived from this individualised knowledge a certain amount of autonomy, or discretion, over the organisation and delivery of daily care. This discretion, together with the agency that care assistants exercised in navigating different institutional logics in this context of care – which was the third main finding – signified a potential nexus of practice change. Conversely, new knowledge or ideas that undermined this limited discretion and agency tended to engender denial or resistance.
As the population ages, demand for long-term care for older people is increasing exponentially, prompting concerns about the capacity and sustainability of this sector. One significant area of concern is workforce recruitment, retention, and competence. This study, located at the intersection of research on long-term care and knowledge translation, contributes to efforts to address these concerns by identifying opportunities for intervention in education, training, and support, in order to build a workforce that is equipped to provide high-quality, evidence-based, person-centred care for older people throughout the years ahead.
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