Abstract: Registered nurses in residential aged care work with older people who have complex care needs. Besides providing direct care, these nurses have a wide range of responsibilities which include supervising staff and attending to the smooth running of the care facility. This grounded theory study using dimensional analysis was aimed at answering the question: How do registered nurses organise their work? Indepth interviews were conducted with 10 registered nurses who worked in a range of positions in aged care facilities. Theoretical sampling and constant comparative analysis was used to guide both ongoing data collectiona and data analysis. Categories were examined for their relationships and dimensions to arrive at a substantive grounded theory which the author has named 'shifting focus'. Individual and institutional philosophies of care were core elements in the registered nurses' focus of work. There was a relationship between staffing adequacy, individual and institutional philosophies of care, and the focus of registered nurse work. These relationships created conditions where the registered nurse would focus on ensuring the delivery of individualised resident care or focus on getting through the routine of care. The relationship between staffing adequacy, philosophies of care and the registered nurses' focus of work remained consistent when staffing adequacy changed. In instances of decreased staffing adequacy, the participants' focus shifted to either maintaining individualised care or focusing on safety. When the registered nurse aimed to change the philosophy of care, an increase in staffing adequacy enabled some aspects of cultural change to commence. The relationships between residents, family and staff were significant contrasting elements within an individualised philosophy of care, and an institutional philosophy of care. In the former, relationships were valued and developed. In the latter, they were benevolent, functional or conflicted. The significance of this study is that it reveals how registered nurses and management personnel in aged care facilities, can create conditions where the relationships between residents, their families and staff, are valued and developed to result in positive care outcomes. It is recommended that future research be conducted to examine the resources required to maintain an individualised approach to the nursing care of residents in aged care facilities.

Abstract: The introduction of nurse practitioner registration into New Zealand in 2001 was heralded as a move that would open up a wealth of opportunities for registered nurses to extend their practice into more independent roles and to provide a client-centred health service. It was also seen as a way to retain experienced registered nurses in the clinical practice area by providing a credible clinical career pathway. If nurse practitioner's are to meet these expectations, then, the author suggests, it is important to understand the processes that encourage or discourage nurses from advancing their practice. One of the early scopes of practice to be introduced was nurse practitioner with an endorsement in aged care scope of practice. Grounded theory was the method used to generate an explanation of how registered nurses working in aged care were preparing for the introduction of nurse practitioner roles. An analysis of early data highlighted codes around registered nurses in aged care extending and advancing their practice rather than preparing specifically for the nurse practitioner role. The research question for this study was: 'How are registered nurses in aged care advancing their nursing practice?' Semi-structured interviews were used to collect data from ten experienced registered nurses working in aged care clinical practice settings ranging from secondary hospital facilities, to community settings and residential care villages. Dimensional analysis of the data eventually generated three major conceptual categories: 'ownership of nursing', 'extending practice', and 'moving out of a comfort zone'. Of these, 'ownership of nursing' was identified as the core construct that linked the other categories together. The substantive theory that explains how registered nurses in aged care advance their clinical practice is 'developing autonomous ownership'. Nurses who develop autonomous ownership of nursing are more likely than other nurses to move out of a current comfort zone and advance their practice into more independent roles that suit their autonomous ownership of nursing. This study identified important contextual factors and conditions that support the development of an autonomous ownership of nursing and that subsequently facilitate advancing nursing practice. These include creating supportive environments, organisational commitment to advanced nursing practice roles, visible nursing leadership, congruence between organisational and nursing philosophies, interdisciplinary collaboration and participating in postgraduate education. The author suggests that the significance of this study is that it generated a theory about the processes that encourage or discourage nurses from preparing for, and progressing into, advanced nursing practice roles such as nurse practitioner.

Abstract: New Zealand statistics project that the aging population of people aged 65 years and over will more than double in the next decade. This has implications for palliative care providers including hospices and hospitals because long-term inpatient care is not generally provided by hospitals and hospices. When dying patients need long-term care, residential settings become an option. The level of palliative care in these facilities is dependent on staff training and numbers. In general, staff are not trained in palliative care, neither do they provide the multidisciplinary facets that define palliative care as undertaken by hospices. This paper describes a practice development initiative using storytelling as the vehicle for introducing the concept of the Liverpool Care Pathway (LCP) for the dying patient into residential aged care settings. With the emergence of a reflective paradigm in nursing the concept of storytelling as a teaching/learning tool has grown. Many staff in residential care settings come from diverse ethnic backgrounds where for some, English is their second language. Storytelling therefore can be a useful approach for learning because it can increase their communication skills. The author suggests that the Liverpool Care Pathway for the dying patient is a model that can be translated across care settings, hospice, hospital, and community. It can demonstrate a framework that facilitates multiprofessional communication and documentation and embraces local needs, culture and language to empower health care workers to deliver high quality care to dying patients and their family/whanau and carers. This paper also explores the role of a facilitator as an agent of change and discusses how the interplay of evidence, context and facilitation can result in the successful implementation of the LCP into residential aged care settings.

Abstract: The Rating Scale for Aggressive Behaviours in the Elderly (RAGE) is a twenty-one item rating scale, designed specifically to measure aggressive behaviours in the elderly in the psychogeriatric inpatient setting. The purpose of the scale is to qualify the aggressive behaviour, note any changes in the behaviour, and record intervention and/or treatments. This study combines both qualitative and quantitative methods with exploratory and descriptive designs to explore nurses' experiences of using a consistent tool for monitoring, measuring and managing aggressive behaviours. Data gathered over a three month period of implementing RAGE aimed to provide a 'snapshot' of the prevalence, extent and type of aggressive behaviours within the inpatient setting, providing evidence to nurses in developing strategies for the management of aggression. Focus group interviews were used to enable nurses to discuss their experiences of utilising a clinically validated tool in their practice and how this made a difference to their practice. Findings from this research indicate that nurses within the setting found that RAGE is a consistent tool with which nurses can record, measure and monitor aggressive behaviours. Responses from nurses' experiences of utilising RAGE in their practice were varied, with some being unable to articulate how RAGE had made a difference to their practice. Despite this there was an overwhelming positive response for the continued use of RAGE within the setting as a clinically validated tool by which to measure, record and manage aggressive behaviours.