Creating a relational arts-based academy for persons living with dementia.

A hospital-university collaboration has created an innovative learning Academy for persons living with dementia. Authors propose essential foundations for creating a different culture of dementia care: a home-like, judgement free place; a relational space focused on artistic expression and discovery; and, the marriage of learning with a deep respect for difference and growth. An array of challenges and insights highlight the commitments required to create and sustain real change. Partnerships with community organizations and schools merged relational philosophy-based research, teaching-learning, and art to generate new patterns of innovative practices. The commitment of the Academy is to relational arts-based inquiry focused on relationships, life enrichment, and engagement in a space where everyone thrives.

Igniting Transformative Change in Dementia Care Through Research-based Drama.

PURPOSE OF THE STUDY: Little research has examined the lasting impact of the arts. As part of a longitudinal research project, we set out to examine how personal images, understandings, and actions of family members (FMs) of persons with dementia and health care professionals (HCPs) change after the introduction of a research-based drama about the experiences of living with dementia called I'm Still Here. This article focuses on the shorter- (6 weeks) and longer-term (12 months) experiences of engaging with I'm Still Here and how those experiences triggered personal transformation. DESIGN AND METHODS: Informed by phenomenology, this article presents findings from follow-up telephone interviews conducted 6 weeks and 12 months after FMs of persons with dementia and HCPs attended a live performance of I'm Still Here. RESULTS: The phenomenological shifts reflected in the longitudinal data suggest a process of engagement with research-based drama that involves four themes: bearing witness to suffering evokes compassion; expanding with new awareness and understanding; finding comfort, confidence, and courage to change; and envisioning and enacting new possibilities. IMPLICATIONS: Findings demonstrate the possibilities of the arts for knowledge mobilization in changing the culture of dementia care through a process of illuminating new and enduring realizations and transforming actions and practices.

Complexity and health coaching: synergies in nursing.

Health care professionals are increasingly aware that persons are complex and live in relation with other complex human communities and broader systems. Complex beings and systems are living and evolving in nonlinear ways through a process of mutual influence. Traditional standardized approaches in chronic disease management do not address these non-linear linkages and the meaning and changes that impact day-to-day life and caring for self and family. The RN health coach role described in this paper addresses the complexities and ambiguities for persons living with chronic illness in order to provide person-centered care and support that are unique and responsive to the context of persons' lives. Informed by complexity thinking and relational inquiry, the RN health coach is an emergent innovation of creative action with community and groups that support persons as they shape their health and patterns of living.

Implications of holding ideas of evidence-based practice in nursing.

The author of this paper examines emerging implications of holding ideas about evidence and evidence-based practice. Evidence has a very specific role in the delivery of safe clinical care, but it is creating a serious problematic for the practice of nursing. It is proposed that: evidence-based practice be re-situated or reconstructed as a collective and organizational responsibility and not the responsibility of individual nurses in practice; nurses re-focus on articulating a more ethical foundation for praxis, one that emerges from nursing philosophy and one that is co-constituted with persons/families/groups; and nurse leaders and educators establish teaching-learning and practice environments that enable a peer-to-peer process of critical review and curious inquiry of available evidence in the contexts of shared work.

Improving client-centered brain injury rehabilitation through research-based theater.

Traumatic brain injury often results in physical, behavioral, and cognitive impairments perceived by health care practitioners to limit or exclude clients' full participation in treatment decision making. We used qualitative methods to evaluate the short- and long-term impact of "After the Crash: A Play About Brain Injury," a research-based drama designed to teach client-centered care principles to brain injury rehabilitation staff. We conducted interviews and observations with staff of two inpatient neurorehabilitation units in Ontario, Canada. Findings demonstrate the effectiveness of the play in influencing practice through the avoidance of medical jargon to improve clients' understanding and participation in treatment; newfound appreciation for clients' needs for emotional expression and sexual intimacy; increased involvement of family caregivers; and avoidance of staff discussions as if clients were unaware. These findings suggest that research-based drama can effect reflexivity, empathy, and practice change to facilitate a client-centered culture of practice in brain injury rehabilitation.

Phenomenological shifts for healthcare professionals after experiencing a research-based drama on living with dementia.

AIM: The aim of this article is to report research findings describing phenomenological shifts, that is, changes in patterns of lived experience, for healthcare professionals who attended a performance of a research-based drama, called I'm Still Here. BACKGROUND: The research drama, based on six studies, was created to help change the ways persons understand, think about and relate with persons living with dementia. METHODS: In 2006-2007, 50 healthcare professionals from various disciplines and eight nursing students participated in this study. Participants were recruited from four Canadian cities in the province of Ontario where focus groups were held before and after engaging in a live performance of I'm Still Here. FINDINGS: Analysis of focus group transcripts showed shifts in patterns of lived experience for the healthcare professional participants as evident in the participants' descriptions. The phenomenological shifts reflected a move from descriptions of 'diminishing humanness to discerning humanness', from 'disengaged care/mundane relating to reflexive relating in the now', and 'terrifying portrayals of loss to awakening to hopeful possibility'. The shifts described herein are supported with examples from the focus group transcripts. CONCLUSIONS: Findings reveal the power of drama as a vibrant and meaningful means of shifting understandings, images and intended actions of healthcare professions which have the potential to affect the lived experiences, relationships and quality of life of persons with dementia.

Dementia care at the intersection of regulation and reflexivity: a critical realist perspective.

OBJECTIVES: To understand point-of-care decisions, and in particular rule breaking, by personal support workers (PSWs) regarding institutionalized elders with dementia within a context of legislative and organizational care mandates. METHODS: Qualitative baseline data including focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) were collected during a 2-year, multi-method trial of a 12-week interprofessional arts-informed educational intervention in two Alzheimer support units and were analyzed using a critical realist approach. RESULTS: PSW care decisions were the outcome of a discordant interrelationship between PSWs' reflective deliberations, and legislative and organizational care mandates. PSWs responded to discordance through rule breaking in order to provide individualized care. Unbeknownst to PSWs, rule breaking was contingent upon supervisors' case-by-case complicity as they strove to balance fears of regulatory citations with private assessment of the soundness of PSW logic. DISCUSSION: Quality care emerges at the intersection of policies governing long-term care, PSW rule breaking, and the supportive but undisclosed role supervisors play in these violations. Understanding this complexity has important implications for initiatives to improve care practices and to challenge legislation and policies that impede dementia care.

Patterns of patient safety culture: a complexity and arts-informed project of knowledge translation.

The purpose of this paper is to describe patterns of patient safety culture that emerged from an innovative collaboration among health services researchers and fine arts colleagues. The group engaged in an arts-informed knowledge translation project to produce a dramatic expression of patient safety culture research for inclusion in a symposium. Scholars have called for a deeper understanding of the complex interrelationships among structure, process and outcomes relating to patient safety. Four patterns of patient safety culture--blinding familiarity, unyielding determination, illusion of control and dismissive urgency--are described with respect to how they informed creation of an arts-informed project for knowledge translation.

Using drama to improve person-centred dementia care.

AIMS AND OBJECTIVES: We implemented a 12-week drama-based educational intervention to introduce to dementia practitioners person-centred care that emphasizes the notion of embodied selfhood (defined as non-verbal self-expression). BACKGROUND: Person-centred dementia care guidelines emphasize the assessment of individual needs, and where appropriate, the use of non-pharmacological interventions before resorting to pharmacological management. However, dementia care is not consistent with these guidelines suggesting conceptual limitations and reliance on passive knowledge translation strategies. DESIGN AND METHODS: Focus groups and semi-structured interviews with practitioners (n = 24) in two nursing homes in central Canada were undertaken to assess the effectiveness of the drama-based components of the intervention. RESULTS: Our findings suggest that drama was effective as an educational modality, and helped implement the person-centred approach into practice. Significant practice outcomes included: new awareness that residents' body movements and dispositions can convey meaning; seeking biographical information from families; increased time efficiency; and supporting residents' independence. CONCLUSIONS: Our findings make an important contribution to person-centred dementia care by broadening the notion of personhood, and by facilitating implementation using drama. IMPLICATIONS FOR PRACTICE: As an enhancement of person-centred care, the support of embodied selfhood may significantly improve residents' quality of life, quality of care, and practitioners' care-giving experience.

Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS.

PURPOSE: The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process. DESIGN AND METHODS: This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada. RESULTS: PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care. IMPLICATIONS: Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents' preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs' nascent occupational identity and their role as interprofessional brokers in long-term care.

Practice in 2050: caring science and a synthesis of views.

In this column nurses influenced by Watson's human caring theory and Eriksson's theory of caritative caring share their ideas about what nursing theory-guided practice will be like in 2050. Following these contributions about caring theories in 2050, is a synthesis of threads of relatedness across the volume 20 Practice Applications columns-all of which focus on possibilities for nursing theory-guided practice in 2050.

The power of imagination: picturing practice in 2050.

The practice columns in this 20th anniversary year are focused on how nursing theory-based practice might evolve and unfold in the future. In this column, nurses affiliated with Neuman's systems model and Rogers' science of unitary human beings imagine what nursing practice guided by their respective theories might look in 2050 and beyond.

Picturing the nurse-person/family/community process in the year 2050.

How will nurses relate with persons in the year 2050? And, how might technology enable or limit the nursing process with persons, families, and communities? These are the questions addressed in this column. Imaging practice in light of the technological imaginings and projections is facilitated by a possible scenario that includes robotics that not only monitor human biological processes, they also emote compassion and caring that may one day be dosed according to the latest diagnostic prescription. Three nurses in this column present their views of how nursing might evolve. Karnick, aligned with the human becoming school of thought, imagines a practice anchored in respect for humanity and quality of life and an accompanying respect for nursing knowledge and nursing work. Senesac and Sato, aligned with Roy's adaptation model, call for nurses to envision and choose the future they want to have. Clear in both perspectives is a reverence for human values and human experience and for the critical role of nursing knowledge as we move toward the not-yet of 2050.

Research-based theatre: The making of I'm Still Here!

This column describes the process undertaken by a team of researchers, artists, and actors to create a research-based drama about living with dementia. Researchers had several studies, guided by the human becoming theory, about what life was like when living with dementia, and an additional study in progress about the lived experience of loss for daughters whose mothers were diagnosed with Alzheimer's disease. Researchers partnered with an experienced artistic director and playwright in order to craft a script and performance that could help others understand and see life with dementia in a new light. The crafting of the script was also informed by the experiences and insights of actors, healthcare professionals, and persons living with dementia. The play premiered before a group of 100 persons and families living with dementia and has since been performed approximately 40 times to hundreds of professionals and families. The evaluation of the play, at six of the performances, is presented in this column.

Human becoming-guided patient-centered care: A new model transforms nursing practice.

Nurses working on an orthopedic surgery and rheumatology unit in a large teaching hospital in Canada participated in a 24-month research project to evaluate what happens when nurses are provided 20% of their time for the purpose of learning and self-development. Half of the teaching-learning was aligned with the commitment of the organization to advance patient-centered care, and in particular patient-centered care guided by the nursing theory, human becoming. The other half was self-directed by nurse participants according to their learning interests and self-development priorities. The purpose of this column is to describe the teaching-learning and mentoring processes in which the nurses were engaged and to highlight the subsequent changes in nursing practice that have happened on the unit from the perspectives of nurse participants.

Challenging the atheoretical production of nursing knowledge: a response to Reed and Rolfe's column.

This column is a response to Reed and Rolfe's column in the January 2006 issue of Nursing Science Quarterly. The authors present their views about Reed and Rolfe's ideas by focusing their discussion and questions on three main topics: the impact of nurses' conceptual thinking, values, and culture on their perspectives and experiences; the reality that nursing theory-guided practice is already a meaningful reality in nursing; and the belief that in order not to limit knowledge development, science must be viewed as more than a study of proximal causes.

Human becoming criticism--a critique of Florczak's study on the lived experience of sacrificing something important.

This article presents a critical appraisal of Kristine Florczak's Parse research method study on the phenomenon of sacrificing something important. The processes of Mitchell's framework for human becoming criticism-sketching the horizon of understanding, illuminating artistic disclosure, and enhancing the original with artform-are utilized.

The experience of being listened to: a qualitative study of older adults in long-term care settings.

The experience of being listened to for older adults living in long-term care facilities was explored using a qualitative descriptive method outlined in Parse (2001), with the human becoming theory as the theoretical framework. The themes that emerged from this study--Nurturing Contentment, Vital Genuine Connections, and Deference Triumphs Mediocrity--affirmed the experience of being listened to as fundamental to the participants' quality of life. The findings expand nursing theory, provide enhanced understanding of the experience of being listened to, and offer ideas for future research. Through the voices of older adults participating in this study, the authors learn how critical listening is to quality care, and thus to excellence in nursing practice.

Feeling respected-not respected: the embedded artist in Parse method research.

The purpose of this column is to present the plan of a research project involving researchers, artists, and research participants. The planned research project will explore with the Parse method eight universal lived experiences important to persons in community. It is anticipated that art works will complement story and text in order to enhance understanding. The authors here present the first attempt of including an embedded artist with Parse method involving one participant who spoke about her experience of feeling respected-not respected. Researcher text and artist works are shown to enhance meaning and understanding.

Exploring the lived experience of waiting for persons in long-term care.

The purpose of this study was to describe the meaning of waiting for persons who reside in long-term care settings. Parse's theory of human becoming provided the nursing perspective and a qualitative descriptive-exploratory design was used. The 45 participants were residents in three different long-term care facilities affiliated with a university. Data were gathered through interviews. Three emergent themes formed the following unified description: The experience of waiting is intensifying ire while diversionary immersions reprieve amid unfolding becalming endurance. The themes are discussed in relation to participants' descriptions, the human becoming theory, and related literature. Recommendations for practice and further research are presented.