Changing disempowering nursing home practices.

The deeply entrenched nursing routines practised in many aged-care facilities pre vent residents receiving the individual care they need, according to researcher Marian Bland.

Bland, now Associate Professor (Nursing) at the Universal College of Learning (UCOL) in Palmerston North, conducted research into the nature of comfort experienced by aged-care residents at three New Zealand nursing homes in 1999-2000. This eventually formed the basis of her PhD thesis, "All the comforts of home? A critical ethnography of residential aged care in New Zealand".

"While comfort is sometimes considered to be simply the absence of discomfort, I found that comfort was instead multidimensional. Residents could be comfortable in some dimensions and uncomfortable in others at the same time. I also identified that 'comfort' is a very individual thing."

As Bland researched what the concept of comfort meant to residents and staff, she became increasingly interested in the culture of nursing homes generally. "When I began my research, I brought with me many assumptions from my experience working in nursing homes. I had to learn to see things through different eyes, especially through the eyes of residents. "I believe nurses need to look at their practice and really ask why they do things the way they do. We need to ask who benefits from these practices. It can be very hard to break entrenched care delivery practices, eg how many times a week a resident is showered, what time they are got ready for breakfast and with whom residents sit in the dining room. Nursing has its own rituals, language and roles within institutional care, but many of these rituals do not serve frail, elderly residents well; they are driven more by a desire for organisational efficiency than the comfort of residents."

Rethinking the purpose of nursing homes

With residents now more frail and with more complex health needs than in previous decades, Bland sees an urgent need for society to rethink the purpose of nursing homes, how they are resourced and staffed. "We expect a great deal of aged-care facilities. They are expected to cater for a diverse range of residents, including those who are close to death, those suffering from varying degrees of dementia, and those Likely to require a home for several years. These facilities are expected to be the residents' homes, but in addition also provide services more commonly associated with hospitals, hotels and hospices. This is an enormous ask and no one facility can fulfil all these expectations.

"Although some residents may live in nursing homes for many years, the fact that 40 percent die within 12 months of admission means that hospice type care is also essential The aged-care industry is trying to cope with a diverse group of people, but it is not resourced adequately, nor does it have the trained staff to cope. We need to look at how registered staff are being used and what training caregivers receive. While it remains acceptable for untrained caregivers to provide much of this care, aged-care facilities will not be able to meet people's expectations of good care."

During her research, Bland observed staff working very hard, but she also saw residents discomforted by some of the nursing and caregiving activities. Many residents, she said, found it hard to Live in a communal environment, and the high staff turnover and use of casual staff in many institutions added to their discomfort.

"It is not always a question of a lack of resources, but often more to do with how we use the resources we have. Individualising care can be difficult, but we owe it to these vulnerable residents to provide resident-centred care and real comfort. This means challenging and changing our disempowering nursing home practices," said Bland.

* A reference copy of Marion Bland's thesis is available in the NZNO national office library.