A qualitative approach to bridging and bonding social capital: Experiences of a cohort of Chilean older people.

With particular focus on availability of family care, research on relationships in later life have often emphasized dynamics inside homes and connections with direct family members. However, a growing number of scholars recognize changes in family practices and the prominence of different types of non-kin ties that are as important as family to older people. Connidis has proposed a sociological approach to capture the realities of personal relationship in later life. Informed by Connidis' approach, we apply qualitative lenses to study social capital in analyzing 40 semi-structured interviews conducted with Chilean people aged 60-74 years. We used a thematic analysis to examine the circumstances under which older people mobilize help through different types of kin and non-kin ties as bonding or bridging social capital. Though literature on social capital describes friends and family members as bonding ties, our findings indicate that they play a double role as bonding and bridging social capital in their own unique way, depending on circumstances. Friends, in comparison to family ties, bridge the older person with a variety of worldviews and lifestyles, helping them to advance their wellbeing in the face of life transitions and challenges experienced with aging. Study participants associated seeking help from others with notions of material and physical dependency, laziness, and a commitment to return help. The preference to seek different types of support from a variety of relationships can be interpreted as a way to manage ambivalence within a larger socio-cultural context.

Public Policy and Experiences of Aging: Social Relationships and Social Integration in Chilean Policy on Aging.

This study uses an interpretive narrative approach to compare and contrast assumptions regarding social integration (participation in meaningful and multiple roles, and engagement in social networks) as promoted in the Chilean Comprehensive Policy for Positive Aging, with the expectations of interviewees aged 60 to 74 years. The Policy assumes specific forms of social integration by: offering different options of social integration to dependent vs. independent older people, encouraging autonomy and self-management, and assuming the primacy of family responsibility in older people's care. Both the Policy and the interviewees emphasize the value of autonomy and independence in old age; the latter, however, do not place family at the frontline when care is needed. Understanding the matches and gaps between policy assumptions and older people's expectations for social integration, including the role of family caregiving, can open new possibilities to prevent social isolation and promote different forms of social support that are valued by older adults for their emotional and practical benefit.

Experiences of people with memory disorders and their spouse carers on influencing formal care: "They ask my wife questions that they should ask me".

BACKGROUND: People with memory disorders often need care and help from family carers and health and social care providers. Due to the deterioration of cognitive capacity and language skills, they may be unable to convey their thoughts and care preferences to other people. As a result, their agency may become restricted. We investigated the descriptions provided by people with memory disorders and spousal carers of their influence on care in encounters with formal care providers. METHODS: Qualitative thematic analysis was used to identify, analyze, and report themes that describe encounters with professionals in different social or healthcare environments. In-depth interview data were gathered from 19 spouse carers and 15 persons with memory disorders. FINDINGS: Three themes out of four describe how people with memory disorders and their spouse carers influence formal care: Acquiescence, negotiating care decisions, and taking control. The fourth theme describes lack of influence. People with memory disorders and their spouse carers have ways to influence care, but spouse carers identified more ways of doing so. Both either accepted and followed the care guidelines by the formal carers or took control of the situation and made their own decisions. Spouse carers also sought to influence care decisions through negotiations with formal carers. When formal carers' decisions were experienced as inconsistent or the rationale of their actions difficult to follow, the possibilities to influence care were limited. CONCLUSIONS: People with memory disorders and their family carers are often in a disadvantaged position as they lack power over the health and social care decision-making during the illness, which is often guided by structural factors. To support the agency of people with memory disorders and to promote shared decision-making, clarification of the service structure and clearer communication between the different parties involved in care are required.

Dementia and Poor Continuity of Primary Care Delay Hospital Discharge in Older Adults: A Population-Based Study From 2001 to 2016.

OBJECTIVES: Delayed discharge, remaining in acute care longer than medically necessary, reflects less than optimal use of hospital care resources and can have negative implications for patients. We studied (1) the change over time in delayed discharge in people with and without dementia, and (2) the association of delayed discharge with discharge destination and with the continuity of primary care prior to urgent admission. DESIGN: A retrospective population-based study. SETTING AND PARTICIPANTS: Delayed discharge after urgent admission and length of delayed discharge were studied in all hospital users aged ≥70 years with at least 1 urgent admission in British Columbia, Canada, in years 2001/02, 2005/06, 2010/11, and 2015/16 (N = 276,299). METHODS: Linked administrative data provided by Population Data BC were analyzed using generalized estimating equations (GEE), logistic regression analysis, and negative binomial regression analyses. RESULTS: Delayed discharge increased among people with dementia and decreased among people without dementia, whereas the length of delay decreased among both. Dementia was the strongest predictor of delayed discharge [odds ratio 4.76; 95% confidence interval (CI) 4.59-4.93], whereas waiting for long-term care placement [incidence rate ratio (IRR) 1.56; 95% CI 1.50-1.62] and dementia (IRR 1.50; 95% CI 1.45-1.54) predicted a higher number of days of delay. Continuity and quantity of care with the same physician before urgent admission was associated with a decreased risk of delayed discharge, especially in people with dementia. CONCLUSIONS AND IMPLICATIONS: This study demonstrates the need for better system integration and patient-centered care especially for people with dementia. Population aging will likely increase the number of patients at risk of delayed discharge. Delayed discharge is associated with both the patient's complex needs and the inability of the system to meet these needs during and after urgent care. Sufficient investments are needed in both primary care and long-term care resources to reduce delayed discharges.

"These Few Blocks, These Are My Village": The Physical Activity and Mobility of Foreign-Born Older Adults.

BACKGROUND AND OBJECTIVES: The self-reported health of foreign-born older adults (FBOAs) is lower than that of nonimmigrant peers. Physical activity (PA) and mobility enhance health in older age, yet we know very little about the PA and mobility of FBOAs. In this analysis we sought to determine: (a) What factors facilitate PA amongst FBOAs? and (b) How do gender, culture, and personal biography affect participants' PA and mobility? RESEARCH DESIGN AND METHODS: We worked closely with community partners to conduct a mixed-method study in Vancouver, Canada. Eighteen visible minority FBOAs completed an in-depth interview in English, Cantonese, Mandarin, Punjabi, or Hindi. RESULTS: Three dominant factors promote participants' PA and mobility: (a) participants walk for well-being and socialization; (b) participants have access to a supportive social environment, which includes culturally familiar and linguistically accessible shops and services; and (c) gender and personal biography, including work history and a desire for independence, affect their PA and mobility behaviors. DISCUSSION AND IMPLICATIONS: We extend the Webber et al. mobility framework, with examples that further articulate the role of gender (e.g., domestic work), culture (cultural familiarity) and personal biography (work history and a desire for familial independence) (Webber, S. C., Porter, M. M., & Menec, V. H. (2010). Mobility in older adults: A comprehensive framework. The Gerontologist, 50, 443-450. doi:10.1093/geront/gnq013). Future programming to support the PA of FBOAs should be culturally familiar and linguistically accessible.

How's Your Health at Home: Frail Homebound Patients Reported Health Experience and Outcomes.

We used a web-based mixed methods survey (HowsYourHealth - Frail) to explore the health of frail older (78% age 80 or older) adults enrolled in a home-based primary care program in Vancouver, Canada. Sixty per cent of eligible respondents participated, representing over one quarter (92/350, 26.2%) of all individuals receiving the service. Despite high levels of co-morbidity and functional dependence, 50 per cent rated their health as good, very good, or excellent. Adjusted odds ratios for positive self-rated health were 7.50, 95 per cent CI [1.09, 51.81] and 4.85, 95 per cent CI [1.02, 22.95] for absence of bothersome symptoms and being able to talk to family or friends respectively. Narrative responses to questions about end of life and living with illness are also described. Results suggest that greater focus on symptom management, and supporting social contact, may improve frail seniors' health.

Job Satisfaction: Insights from Home Support Care Workers in Three Canadian Jurisdictions.

This mixed-methods study identified the personal and workplace characteristics that drive the job satisfaction of home support workers (HSWs) providing assistance to elderly clients. Data were based on a standardized measure of job satisfaction, along with in-depth qualitative interviews with 176 home support workers from three Canadian provincial jurisdictions (British Columbia, n = 108; Ontario, n = 28; Nova Scotia, n = 40). We anticipated that variability in demographic profiles between the three groups of workers and different job descriptions would be associated with differences in perceived job satisfaction. This was not the case. Results from the qualitative analysis highlight key areas that contributed to job satisfaction. These are job (scheduling, travel, and safety), economic (income security), and organizational (communication, support, and respect) factors. Given these findings, we recommend improvements to workplace communication, increased travel time allowance between clients, and wage parity with equivalent positions in long-term care facilities.

Types and patterns of safety concerns in home care: client and family caregiver perspectives.

OBJECTIVE: Drawing on interviews with home care clients and their family caregivers, we sought to understand how these individuals conceptualize safety in the provision and receipt of home care, how they promote safety in the home space and how their safety concerns differ from those of home support workers. DESIGN: In-depth, semi-structured interviews were conducted with clients and family caregivers. The analysis included topic and analytical coding of participants' verbatim accounts. SETTING: Interviews were completed in British Columbia, Canada. PARTICIPANTS: Totally 82 clients and 55 caregivers participated. RESULTS: Clients and family caregivers identified three types of safety concerns: physical, spatial and interpersonal. These concerns are largely multi-dimensional and intersectional. We present a conceptual model of client and caregiver safety concerns. We also examine the factors that intensify and mitigate safety concerns in the home. CONCLUSIONS: In spite of safety concerns, clients and family caregivers overwhelmingly prefer to receive care in the home setting. Spatial and physical concerns are the most salient. The financial burden of creating a safe care space should not be the client's alone to bear. The conceptualization and promotion of safety in home care must recognize the roles, responsibilities and perspectives of all of the actors involved, including workers, clients and their caregivers.

Home support workers perceptions of family members of their older clients: a qualitative study.

BACKGROUND: Health care discourse is replete with references to building partnerships between formal and informal care systems of support, particularly in community and home based health care. Little work has been done to examine the relationship between home health care workers and family caregivers of older clients. The purpose of this study is to examine home support workers' (HSWs) perceptions of their interactions with their clients' family members. The goal of this research is to improve client care and better connect formal and informal care systems. METHODS: A qualitative study, using in-depth interviews was conducted with 118 home support workers in British Columbia, Canada. Framework analysis was used and a number of strategies were employed to ensure rigor including: memo writing and analysis meetings. Interviews were transcribed verbatim and sent to a professional transcription agency. Nvivo 10 software was used to manage the data. RESULTS: Interactions between HSWs and family members are characterized in terms both of complementary labour (family members providing informational and instrumental support to HSWs), and disrupted labour (family members creating emotion work and additional instrumental work for HSWs). Two factors, the care plan and empathic awareness, further impact the relationship between HSWs and family caregivers. CONCLUSIONS: HSWs and family members work to support one another instrumentally and emotionally through interdependent interactions and empathic awareness. Organizational Care Plans that are too rigid or limited in their scope are key factors constraining interactions.

Nurses negotiating professional-familial care boundaries: striving for balance within double duty caregiving.

The purpose of this sequential, two-phase mixed-methods study was to examine the health of male and female nurses who provided care to older relatives (i.e., double duty caregivers). We explored the experiences of 32 double duty caregivers, which led to the development of an emergent grounded theory, Negotiating Professional-Familial Care Boundaries with two broad dialectical processes: professionalizing familial care and striving for balance. This article examines striving for balance, which is the process that responds to familial care expectations in the midst of available resources and reflects the health experiences of double duty caregivers. Two subprocesses of striving for balance, reaping the benefits and taking a toll, are presented in three composite vignettes, each representing specific double duty caregiving (DDC) prototypes (making it work, working to manage, living on the edge). This emergent theory extends current thinking of family caregiving that will inform the development and refinement of practices and policies relevant to DDC.

Professionalizing familial care: examining nurses' unpaid family care work.

An emergent grounded theory was used to examine Professionalizing Familial Care, the processes by which registered nurses enact professional care work within the familial care domain. A sample of registered nurses (n = 32) were interviewed by telephone at multiple time points over a 6- to 12-month period. The findings revealed that the professionalization of care work was often reinforced by societal, familial, and self-expectations. Setting Limits and Making Connections were the dialectical overarching processes shaping the professionalizing of care while 6 interdependent substrategies emerged: assessing, advising, advocating, collaborating, coordinating, and consulting. These findings will help inform refinement of policies and practices for nurses who provide care for an older relative.

Ethno-cultural diversity in the experience of widowhood in later life: Chinese widows in Canada.

This paper utilizes Helena Znaniecka Lopata's concept of life frameworks as a lens through which to understand the experience of widowhood amongst elderly Chinese immigrant women living in Toronto, Canada. While Lopata defined life frameworks as including social supports, social relations and social roles, for these widows, personal resources (framed in Chinese cultural context) were also important aspects of life frameworks. In-depth interviews with 20 widows contacted through a Chinese community center were conducted in Mandarin and Cantonese and then transcribed and interpreted through team-based qualitative analyses. These women ranged in age from 69 to 93 years and had been in Canada an average of 17 years, with over half of them widowed following immigration. Our analysis framed the widows' narratives in terms of four types of supports defined by Lopata: social, service, financial and emotional supports. They had fairly extensive social and service supports focused primarily around family and the Chinese community. Although norms of filial piety traditionally dictate sons as primary supports, daughters predominated as providers of supports to these widows. Interpreted from a life course perspective, financial supports were deemed sufficient, despite overall limited financial means. Emotional support was more nuanced and complex for these widows. Loneliness and feelings of social isolation were prevalent. Nevertheless, themes of acceptance and satisfaction dominated our findings, as did reciprocity and exchange. The narrative accounts of these widows depict a complexity of experience rooted in their biographies as Chinese women and as immigrants, rather than primarily in widowhood itself.

Workers' experiences of crises in the delivery of home support services to older clients: a qualitative study.

In the provision of care to older clients, home support workers regularly confront, avert, and manage crises. Semistructured interviews were conducted to explore the nature, type, and management of crises from the perspective of home support workers (N = 118) of older persons in British Columbia, Canada. The delivery of home health care occurs within a context of unpredictability related to scheduling, time constraints, variability of client need, and changing work environments. These events are experienced by 91% of home support workers and range from a serious medical incident (e.g., fall, death) to an interpersonal dilemma (e.g., client refusal of service, argument between worker and family member). Home support workers use a variety of strategies to manage these incidents. The analysis of crises enables us to better understand how agency and care policies may be more responsive to circumstances that challenge care work in home health settings.

Types and patterns of safety concerns in home care: staff perspectives.

BACKGROUND: Quality health care in the home is dependent on having a safe environment to provide care. This analysis is based on the data from a larger study aimed at understanding key issues in the delivery and receipt of home support services from the perspectives of home support workers (HSWs), older adult clients and family members. This analysis focuses on HSWs perspectives of safety. OBJECTIVE: To explore the types and patterns of safety concerns staff encountered in home care settings. DESIGN: In-depth, semi-structured interviews were conducted with HSWs. The analysis included topic and analytical coding of workers' verbatim accounts. SETTING: Interviews were completed in British Columbia, Canada. PARTICIPANTS: A total of 115 HSWs participated. The average age was 50 years, and the average tenure in this sector was 11.5 years. Fully, 71% of workers had completed at least some college-level education, and 69% of workers were born outside of Canada. RESULTS: Workers identified four types of safety concerns: physical, spatial, interpersonal and temporal. We developed a conceptual model of HSW safety that demonstrates the: types of safety concerns; the multi-dimensional and intersectional nature of safety concerns and the factors that intensify or mitigate safety concerns. CONCLUSIONS: Our study identifies numerous HSW safety concerns, each requiring tailored interventions and strategies. Where multiple concerns intersect, the complexity and precarious nature of the home care workspace is revealed. The identification of mitigating and intensifying factors points to future interventions.

"I'm satisfied but": clients' and families' contingent responses about home care.

Home care service organizations need a means of gaining useful feedback about satisfaction with care from clients and their families. Interviews were conducted with 82 older adult clients and 52 family members about their satisfaction with home care. A subgroup of participants (n = 39) provided "contingent" satisfaction responses. Contingent responses reflect the duality of perceptions that clients and families convey about services. Three themes emerged as critical to understanding these types of responses: adept versus inept staff, predictable versus precarious scheduling, and responsive versus restrictive care plans. Understanding the reasons for contingent responses could help home care agencies to target quality improvement initiatives for individual clients and families.

Key issues in human resource planning for home support workers in Canada.

OBJECTIVE: This paper is a synthesis of research on recruitment and retention challenges for home support workers (HSWs) in Canada. PARTICIPANTS: Home support workers (HSWs) provide needed support with personal care and daily activities to older persons living in the community. METHODS: Literature (peer reviewed, government, and non-government documents) published in the past decade was collected from systematic data base searches between January and September 2009, and yielded over 100 references relevant to home care human resources for older Canadians. RESULTS: Four key human resource issues affecting HSWs were identified: compensation, education and training, quality assurance, and working conditions. To increase the workforce and retain skilled employees, employers can tailor their marketing strategies to specific groups, make improvements in work environment, and learn about what workers value and what attracts them to home support work. CONCLUSIONS: Understanding these HR issues for HSWs will improve recruitment and retention strategies for this workforce by helping agencies to target their limited resources. Given the projected increase in demand for these workers, preparations need to begin now and consider long-term strategies involving multiple policy areas, such as health and social care, employment, education, and immigration.

Revisiting widowhood in later life: changes in patterns and profiles, advances in research and understanding.

This analysis reviews the ways in which both the experience of widowhood in old age and the nature of research on widowhood have changed since the publication of the book Widowhood in Later Life in 1991. Patterns of decline in widowhood in both its duration and incidence in later life are examined. Widowhood research has advanced conceptually by moving beyond understanding widowhood solely in terms of role loss. Life course perspectives, and concepts of multiple narratives and of resilience, have also contributed to the field. New methodologies, including prospective and longitudinal designs involving larger data sets, and more in-depth qualitative studies, have advanced our understanding of complexities and variations in widowhood. These include issues of gender and ethnocultural diversity, as well as the intersection of wealth, health, and class. This article also examines how patterns of labour force affiliation, social policy, and the changing nature of marriage shape widowhood in later life.