Author: Anita Marie De Bellis
De Bellis, Anita Marie, 2006 Behind Open Doors - A Construct of Nursing Practice in an Australian Residential Aged Care Facility, Flinders University, School of Nursing & Midwifery
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This thesis explored the relationship between the discourses of nursing care, the nursing care provision, and the perceived nursing care needs of three highly dependent residents in a residential aged care facility in Australia. Residential aged care in this country has undergone major reforms since 1987 and the nursing profession has struggled with these changes because of the documentation, validation, and accreditation requirements; the inadequate determination of dependency on nursing care for funding; the Registered Nurse (RN) being removed from the bedside to a role of scribe and delegator; the increasing acuity and complexity of the residents' needs; an increase in the turnover of residents; a rise in the nursing staff attrition rate; the delivery of care by untrained and unqualified persons; the RN being accountable and responsible for the care given by 'non-nurses' from a distance; and, the inadequate skill mix and staff to resident ratios provided in these institutions. The interest of this thesis was to research gerontological nursing practice in the context of residential aged care. Residential Aged Care Facilities (RACFs) in Australia that care for the highly dependent elderly were identified in the thesis as disciplinary institutions that used 'subjectivation' as a means to control the efficiency and effectiveness of the labour force and the 'docile' bodies of the residents, whilst at the same time the government rhetoric is that of the quality of life standards and the rights of residents in these institutions. As well as the discourse analysis, an historical overview of the aged care reforms in Australia was undertaken for the period from 1975 to 2006 that demonstrated the effects the reforms have had on the voice of nurses and nursing care in these institutions. This analysis highlighted where nurses have been silenced and found the federal government determining what is nursing care and what is not nursing care, and also who is providing this nursing care. Using a case study approach and discourse analysis each of the three residents was studied using data from five sources namely the resident or relative, a RN, a careworker (CW), the current documentation pertaining to the resident's nursing care, and the non-participant observation of the nursing care provided. These discourses on the nursing care and perceived residents' nursing care needs were analysed using the theoretical base developed from the philosophy and research interest of Michel Foucault (1926-1984), who questioned the apparatus and institutions of Western cultures and searched for discontinuities in the practices of what he termed 'disciplines'. The results of the discourse analysis found nursing care practices that were alarming around the residents' perceived nursing care needs, the documentation of the nursing care provision, and the observed 'actual' nursing care provided. A questionable standard of nursing care was evidenced even though this facility had recently been accredited. A custodial level of mechanistic care was provided to residents in an extremely noisy and public environment within a culture of haste and bustle by unknowledgeable CWs, under the distant gaze of a RN, and the direction of the government documentation requirements. This resulted in unsafe, unethical, unprofessional, and negligent practices, as well as fraudulent, illegal, and dangerously out of date documentation practices. This was ultimately affecting each resident's quality of life, nursing care, and wellbeing and was an added burden on the residents' relatives. Many discontinuities, dissonances, conflicts, and contradictions in nursing practice were uncovered for these three highly dependent residents that may be transferable and similar to other highly dependent residents in this and other institutions. Indeed it may mirror other disciplines that provide care services, such as mental health care, acute care, and disability care provision. The concerns for the nursing profession have epistemological, ethical, and political ramifications for the residents and their relatives, the nurses, the non-nurses doing nursing work, the government, and the industry. Epistemologically new nursing 'knowledges' were being developed that were not resident focussed or based on evidence. Ethically, the legislated rights of residents were not being supported, despite the accreditation, funding, and complaint mechanisms in place - and this has the potential to have punitive ramifications for the industry. Professionally and politically, CWs were identified as non-nurses doing nursing work of a poor standard. This care was not based on accepted nursing practice, but developed through the documentation requirements of the federal government department, the applied constraints, and the CWs themselves. Furthermore, the documentation requirements were found to be a pretence in regard to funding through validation and accreditation, as well as a charade in nursing practice. There is presently a substantial third level of nurses who are identified legally and political as non-nurses doing non-nursing work (known as 'personal' care); but these non-nurses are doing nursing work and are identified by the nursing profession and the public as 'nurses' doing nursing work. These non-nurses who provided nursing care are not educated, licensed, or regulated, and are not accountable professionally to nurses or legally to the public. It is proposed that CWs are in need of licensing under nurses' boards requiring at the very least a minimum of training and education. It is further proposed that documentation requirements resort back to professional nursing documentation; funding be dependent on an predetermined minimum skill mix and staff/resident ratio; and the funding of residents be based on a minimum data set and untied from nursing practice. The professional nursing practice of assessment, planning, implementation, and evaluation of nursing care needs resorting to a nursing domain of knowledge, practice, accountability, responsibility, and documentation. If an acceptable quality of life is to be realised for residents in the residential aged care system, given that highly dependent residents are reliant on quality nursing care that is fundamentally imperative to their very quantity and quality of life, then changes in the residential aged care system and the nursing profession will be necessary. This thesis will contribute to opening up such dialogue between the government, the industry, and the nursing profession in Australia, and it also highlights areas of aged care nursing practice in need of further research.
Keywords: aged care,nursing practice,quality of nursing care,aged care policy
Subject: Nursing thesis
Thesis type: Doctor of Philosophy
School: School of Nursing & Midwifery
Supervisor: Dr Patricia Mitchell