Social Participation in Long-term Residential Care: Case Studies from Canada, Norway, and Germany.

Meaningful social engagement in everyday activities can enhance resident quality of life in nursing homes. In this article, we draw on data collected in a multidisciplinary, international study exploring promising practices in long-term care homes across Canada, Norway, and Germany, to investigate conditions that either allow for or create barriers to residents' social participation. Within a feminist political economy framework using a team-based rapid ethnography approach, observations and in-depth interviews were conducted with management, staff, volunteers, students, families, and residents. We argue that the conditions of work are the conditions of care. Such conditions as care home location, building layout, staffing levels, and work organization, as well as governing regulations, influence if and how residents can and do engage in meaningful everyday social life in/outside the nursing home. The presence of promising conditions that facilitate resident social participation, particularly those promoting flexibility and choice for residents, directly impacts their overall health and well-being.

Supporting Family Involvement in Long-Term Residential Care: Promising Practices for Relational Care.

Family members and friends provide significant support for older relatives in long-term residential care (LTRC). Yet, they occupy ambiguous positions in these settings, and their relationships with LTRC staff can involve conflicts and challenges. Based on an ethnographic project carried out in North America and Europe, this article identifies practices that promote meaningful family participation in care home life. We consider instances of rewarding family involvement upon admission to LTRC, throughout the time a relative is living in a care home, and during the final stages of life. Furthermore, we identify working conditions needed to support the well-being of family/friend carers as well as residents and staff. These include greater appreciation of relational care work, time for effective communication, teamwork, and appropriate, inclusive physical spaces. Findings make visible the importance of relational care and have implications for improving living and working conditions in LTRC.

"Leisurely Dining": Exploring How Work Organization, Informal Care, and Dining Spaces Shape Residents' Experiences of Eating in Long-Term Residential Care.

Mealtimes are among the busiest times in nursing homes. Austerity measures resulting in insufficient staff with heavy workloads limit the amount of time available to assist residents with eating. Within a feminist political economy framework, rapid team-based ethnography was used for an international study involving six countries exploring promising practices and also for a study conducted in one Canadian province in which interrelationships between formal and informal care were investigated. Data collection methods included interviews and observations. In addition, dining maps were completed providing a cross-jurisdictional comparison of mealtime work organization, and illustrating the time spent assisting residents with meals. Dining maps highlight the reliance on unpaid care as well as how low staffing levels leave care providers rushing around, preventing a pleasurable resident dining experience, which is central to overall health and well-being.

Liminality in Ontario's long-term care facilities: Private companions' care work in the space 'betwixt and between'.

Nursing, personal care, food and cleaning are publicly funded in Ontario's long-term care facilities, but under-staffing usually renders all but the most basic of personal preferences superfluous. This individualization of responsibility for more personalized care has resulted in more families providing more care and opting to hire private, private companion care. With direct payment of companions becoming a growing but largely invisible facet of care, exploring companion's roles is important. Using a six site rapid ethnographic study in long-term care facilities (i.e. observations, documents and key informant interviews (n=167)), this paper argues that private companions occupy a liminal space between policy, family and market, and their role within institutions and in private homes may be the missing link in the care work chain in the sense that it can at once be classified as formal and informal and draws on their own and others paid and unpaid labour.

The Meaning of 'Dining': The Social Organization of Food in Long-term Care.

OBJECTIVE: To explore the social organization of food provision in publicly funded and regulated long-term care facilities. METHODS: Observations were conducted, along with 90 interviews with residents, families, and health providers in two Southern Ontario sites using rapid site-switching ethnography within a feminist political economy framework as part of an international, interdisciplinary study investigating healthy ageing. RESULTS: Food is purchased within a daily $7.80/per resident allotment, limiting high quality choices, which is further problematized by privatization of food services. Funding restrictions also result in low staffing levels, creating tensions in aligning with other Ministry mandated tasks such as bathing, and documenting: competing demands often lead to rushed meals. Regulations, primarily set in response to scandals and to ensure appropriate measured nutrition, reinforce the problem. Further, regulations regarding set meal times result in lack of resident agency, which is compounded by fixed menu options and seating arrangements in one common dining room. Rather than being viewed as an important part of resident socialization, food is reduced to a medicalized task, organized within a climate of cost-containment. IMPLICATIONS: Findings warrant Ministry financial support for additional staff and for food provision. Policy changes are also required to give primacy to this population's quality of life.

Women's strategies to achieve access to healthcare in Ontario, Canada: a meta-synthesis.

As part of a mixed methods study on women's access to the healthcare system in Ontario, Canada, we undertook a qualitative meta-synthesis to better understand the contextual conditions under which women access healthcare. An earlier phase of the synthesis demonstrated a series of factors that complicate women's access to healthcare in Ontario. Here, we consider women's agency in responding to these factors. We used meta-study methods to synthesise findings from qualitative studies published between January 2002 and December 2010. Studies were identified by searches of numerous databases, including CINAHL, MEDLINE, Scopus, Gender Studies Database and LGBT Life. Inclusion criteria included use of a qualitative research design; published in a peer-reviewed journal during the specified time period; included a sample at least partially recruited in Ontario; included distinct findings for women participants; and in English language. Studies were included in the final sample after appraisals using a qualitative research appraisal tool. We found that women utilised a spectrum of responses to forces limiting access to healthcare: mobilising financial, social and interpersonal resources; living out shortfalls by making do, doing without, and emotional self-management; and avoiding illness and maintaining health. Across the studies, women described their efforts to overcome challenges to accessing healthcare. However, there were evident limits to women's agency and many of their strategies represented temporary measures rather than viable long-term solutions. While women can be resourceful and resilient in overcoming access disparities, systemic problems still need to be addressed. Women need to be involved in designing and implementing interventions to improve access to healthcare, and to address the root problems of these issues.

Diabetes care and mental illness: constraining elements to physical activity and social participation in a residential care facility.

OBJECTIVE: To explore barriers and constraints to physical activity, as an integral component of diabetes care, in those with serious mental illness who reside in a for-profit group home. METHODS: Institutional ethnography was the approach used to explore diabetes-related care practices among 26 women in a rural residential care facility in southern Ontario. Semi-structured, in-depth interviews were conducted with residents who had diabetes as well as with care providers, field workers and health professionals. Observations and document analysis were further methods used to reveal the disjuncture between diabetes care guidelines and the actualities of living within imposed constraints of group home care. RESULTS: The residents in this government-regulated group home were sedentary, obtaining approximately 10 minutes per day of low-intensity exercise. The overarching government interest in cost containment created a context of rationing that resulted in a lack of opportunities to exercise and fully participate in social life. Furthermore, group home policies regulated systems of safety, reporting and financial accountability, but did not promote health. CONCLUSIONS: The findings indicate an urgent need for government financial support for quality of life initiatives and amendments to group home policies that give primacy to health promotion, illness prevention and medical management of prevalent comorbid conditions such as diabetes.

Diabetes care and mental illness: the social organization of food in a residential care facility.

OBJECTIVE: To explore the social organization of food provision and dietary intake in seriously mentally ill people with diabetes who reside in a for-profit group home. METHODS: Institutional ethnography was used to explore diabetes-related care practices among 26 women in a rural residential care facility in southern Ontario. Semi-structured, in-depth interviews were conducted with residents with diabetes, care providers, field workers, and health professionals. Observations and document analysis were also used to understand the lack of congruence between diabetes guidelines and the possibilities for diabetes management within the confines of group home care. RESULTS: Although it was mandated in group home guidelines that "Health Canada's Eating Well with Canada's Food Guide" (2007) be followed, menus were planned within the context of a limited food budget of approximately $1.91 per day per resident. Group home policies regulated systems of safety, reporting, and financial accountability, but not health promotion. Inspections carried out by the Public Health Department focused primarily on food safety during handling, preparation, and storage, and compliance to regulations regarding environmental cleanliness and infection control. CONCLUSION: Resource rationing found in group home care exacerbates illness in an already marginalized group. Financial support is required to enable provision of healthy food choices, including dairy products, fresh fruits, and vegetables. Additional support is required for care of co-morbid conditions such as diabetes for associated food costs and education to improve outcomes. Group home policies must take into consideration health threats to this population and give primacy to health promotion and illness prevention.

Beyond barriers in studying disparities in women's access to health services in Ontario, Canada: a qualitative metasynthesis.

Women live within complex and differing social, economic, and environmental circumstances that influence options to seek health care. In this article we report on a metasynthesis of qualitative research concerning access disparities for women in the Canadian province of Ontario, where there is a publicly funded health care system. We took a metastudy approach to analysis of results from 35 relevant qualitative articles to understand the conditions and conceptualizations of women's inequitable access to health care. The articles' authors attributed access disparities to myriad barriers. We focused our analysis on these barriers to understand the contributing social and political forces. We found that four major, sometimes countervailing, forces shaped access to health care: (a) contextual conditions, (b) constraints, (c) barriers, and (d) deterrents. Complex convergences of these forces acted to push, pull, obstruct, and/or repel women as they sought health care, resulting in different patterns of inequitable access.