This dissertation considers how certified nursing assistants (CNAs) construct the bodies of nursing home residents and how they assign meaning to work that is commonly viewed in one way or another as "dirty", tainted, or undesirable. CNAs invoked dignifying discourses to reinterpret meanings of their stigmatized work to mitigate the degrading implications of their labors. Together, body constructions and dignifying discourses shape the hands-on, intimate care aides provide to nursing home residents.

Observations and interviews were conducted with 27 aides in three different types of nursing homes in California. Other data included a content review of texts such as job descriptions and observations of aide training classes. All participants were people of color and, except for three aides, were first generation immigrants. Most were women and reflected U.S. demographics of CNAs working in metropolitan areas.

Nursing assistants constructed three distinct views of residents: resident as fictive kin, resident as commodity, and resident as autonomous person. Related dignifying discourses supported each construct and helped produce enactments of care giving. Caring practices were influenced by institutional forces such as commodifying the physical body while cultural understandings entered the rhetorics of duty and caring. The dominant discourses did not arise from training or other official sources but were generated by aides themselves in the course of their work. These findings extend the concept of "dirty work" to nursing assistants and contest some conventional views that aides accept stigmatized labels of their work.

Implications for practice confirm other studies that recommend changes in the length and content of aide training. These findings also offer possible directions for nursing home policies to enhance worker retention and satisfaction. Areas for future research include taking up the central inquires across several contexts, such as in rural nursing homes and among licensed nurses and residents and their families. Additionally, the increasing globalization of healthcare workers would benefit from a closer look at the way immigrant workers experience and practice carework.

Pain is a significant problem for nursing home residents. Pain assessment is complicated by the high prevalence of cognitive loss in this population. Because licensed nurse (LN) staffing levels are low in nursing homes, the majority of resident care is performed by certified nursing assistants (CNAs) who do not have formal training or skills to assess or manage pain. CNAs' role in the assessment and management of pain in nursing home residents is not well understood, because few studies have explored this issue.

To address this gap in our knowledge, a qualitative study using Grounded Theory Methodology was undertaken. The study was conducted at two skilled nursing facilities: Memory Care Units within a large county run hospital and at a 99 bed for-profit corporate owned facility. Twenty-six individuals were interviewed (16 CNAs and 10 LNs) using semi-structured interview guides. CNAs were asked about their experiences caring for residents in pain. LNs were asked about how they perceived CNAs' role in pain management. Interviews were transcribed verbatim and analyzed using grounded theory constant comparative methods.

Both CNAs' and LNs perceived that CNAs had a role in the pain management of nursing home residents. CNAs' recognized pain by using techniques of asking and listening and by observing behaviors. They distinguished pain that they considered normal (everyday pain) from pain that they reported to LNs. As well as reporting pain, they responded to residents who had pain by performing resident-centered care, giving physical care and providing attention to distract residents from their pain. Their ability to do this work was founded on their understanding of pain as multidimensional and their intimate knowledge of individual residents. They described their knowledge of residents as being informed by two types of knowing: working knowledge and knowing residents as individuals. Contextual factors that both promoted and hindered CNAs having a role in pain management were identified. These factors included CNAs' individual skills and experience, low levels of staffing, and working more than 40 hours a week. From this understanding of CNAs' role in pain management, implications for clinical practice and research are identified.

Background: Age-related hearing loss effects negatively on an individual’s physical, psychosocial, and social status. Hearing loss may be accelerated in patients taking ototoxic medications. Given the high prevalence of hearing loss, drug-related ototoxicity among older adults may be a critical public health problem.

Objectives: The aims of this dissertation were: 1) to identify risk factors of age-related hearing loss from a literature review; 2) to explore the prevalence of ototoxic medication use and the associated factors for ototoxic medication use; 3) to investigate the association of ototoxic medication use with incidence and progression of hearing loss.

Methods: A search of the literature on risk factors for age-related hearing loss was performed using the electronic PubMed database. The research data were extracted from the Epidemiology of Hearing Loss Study datasets. The cohort was examined in 1993-1995 (n = 3753), 1998-2000 (n = 2800), and 2003-2005 (n = 2395) in Beaver Dam, Wisconsin. Medication use was obtained from the standardized questionnaire that was administered by the examiners. Hearing loss was defined as a pure tone average at 500, 1000, 2000, and 4000 Hz greater than 25 dB HL in either ear.

Results: The Literature review revealed that the most consistently strong risk factors for age-related hearing loss across the studies were genetics, current smoking, diabetes, cardiovascular diseases, and obesity. The prevalence of any ototoxic medication use increased from 84% to 91% over the 10-year follow-up period. Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and diuretics were common ototoxic medications taken by older adults. Hypertension, diabetes, cardiovascular diseases, and history of smoking were associated with ototoxic medication use. Participants who took loop diuretics had a high incidence of hearing loss for 10 years. Participants who took NSAIDs or a loop diuretic had worse progression of hearing loss over 10 years. Also, the use of concomitant ototoxic medications was associated with the incidence and severity of hearing loss.

Conclusion: Ototoxicity may interact with aging leading to a more severe hearing loss than that associated with age alone. The findings suggest that ototoxic medications should be considered a potentially modifiable contributor to age-related hearing loss.

Sudden cardiac death is an unanticipated event, resulting from a cardiac rhythm disturbance. The best option for reducing risk and improving survival in high risk populations is the implantable cardioverter defibrillator (ICD). More individuals are receiving and living with ICDs at advanced ages and for longer periods. Yet, scant research has studied the perspective of individuals who are dealing with the implanted technology while also managing aspects of advancing age in a community setting.

Using qualitative grounded theory methodology, the question of how an ICD affects the daily life of persons living with an ICD was explored. Human subjects¡&hibar; approval was obtained from the sponsoring university¡&hibar;s human subjects committee and approval from the recruitment site was received before the study was started. Twenty-four older adults (¡Ý65) who had lived with an ICD from two to 19 years were recruited from the device clinic of a tertiary care hospital. Data collection consisted of interviews that lasted 30-90 minutes and were conducted with a semi-structured interview guide.

Data collection and analysis occurred in alternating sequences as initially described by Glaser and Strauss (1967) and further informed by Charmaz (2006) and Clark (2005). The researcher transcribed verbatim and then checked transcriptions with audio recordings. Initial open coding examined minute sections of text followed by axial and selective coding in order to determine salient themes and properties that emerged from the data. Data was also collected in the form of analytic and self-reflective memos and positional maps. Theoretical and methodological notes were maintained regarding decisions made during the process.

Study data revealed, the core process of ¡°Living in Partnership¡± that can be characterized by three phases: Entering into a Partnership, Managing the Partnership, and Contemplating or Not Contemplating Dissolving the Partnership. The findings provided insights into the ways older adults come to understand the ICD in the context of their daily lives and serve to inform practitioners involved in their care. Further research focusing on personal meaning and impact is needed to plan for situations along the continuum of living with an ICD and dealing with advancing age.

Using menopausal hormone therapy (HT) for more than five years puts women at increased risk for breast, ovarian, and endometrial cancer, cardiovascular disease (CVD), gallbladder disease, incontinence, and dementia. For this reason, HT is not recommended beyond this therapeutic window, except in rare circumstances. Nevertheless, data on filled prescriptions indicate that over a third of HT prescriptions are written for women over age 60. These alarming facts raised the research questions: "What factors influence older women to use HT beyond the menopause transition?" and "How do older women weigh the risks and benefits of HT?"

Conventional grounded theory methods were used to interview 30 long-term users of systemic HT, code transcripts, and analyze data. Results showed that long-term users perceived that HT gave them control of numerous symptoms they attributed to menopause, enabled them to maintain attributes associated with youth and femininity, and helped them avoid diseases associated with aging, such as dementia and CVD. Risk was rarely mentioned in interviews; it was generally disregarded; and most participants did not know that age and length of HT use increase the risk of breast cancer. Users were observed to be the primary drivers of long-term HT, although gynecology specialty providers played a major role by giving reassurance about risk and continuing to prescribe HT.

Arguing that the science behind the quantification of HT risk is faulty, some hormone manufacturers promote HT for long-term use. This promotion is largely directed at gynecology specialists through strategies such as ghostwriting, and, as a consequence, many of them remain skeptical of prescribing guidelines that recommend limiting duration of use. Key concepts from the literature on decision making that help explain disregard of risk information were identified.

Study findings are applicable to any clinical encounter that involves weighing benefit and risk. Recommendations to providers: Learn to distinguish science from marketing. Help patients understand that positive feelings about treatment may be based on unrealistic expectations for efficacy and underestimation of risk. Discuss judgment biases and cite base rates when providing risk statistics in clinical encounters. Such interventions could potentially strengthen joint decision making and improve patient outcomes.

The portion of older adults with schizophrenia is growing and their physical health status is poor. Many factors contribute to poor physical health including unhealthy lifestyles, poorly managed chronic diseases, and socio-demographic factors. The purpose of this dissertation was to explore how older adults with schizophrenia understand their physical health

A quantitative secondary data analysis was conducted based on a randomized lifestyle intervention program for older persons with schizophrenia or schizoaffective disorder and diabetes mellitus recruited from board-and-care facilities and day treatment programs to explore the relationship between the symptoms of schizophrenia experienced and response to the intervention. The qualitative aspect was conducted using a grounded theory approach to guide interviews with 28 older adults with schizophrenia or schizoaffective disorder recruited from three mental health facilities to explore the individual understanding of physical health.

The quantitative study revealed a significant condition by symptom interaction for diabetes knowledge. The difference between change in knowledge for intervention and control groups depends on prevalence and severity of total, negative, and general symptoms. There was not a significant condition by positive symptom interaction for diabetes knowledge. A significant main effect was found between total, negative, positive, and general symptoms in the total sample for diabetes self-efficacy. Higher prevalence and severity of symptoms was negatively associated with improvement in diabetes self-efficacy.

The qualitative data revealed that while discussing conceptions of physical health, participants spoke about a sense of belonging as one of the key factors supporting feeling healthy. A sense of belonging could be derived from a sense of connection with others, a physical place, social relationships, and a sense of meaning and purpose. Also, the concept of trust between participants, health care providers, and the health care system emerged as a dynamic process that was built with factors of respect, caring, advocacy, and consistency and eroded through factors of disrespect, not being heard, lack of time, provider inaction, and stigmatization.

The symptoms and experience of schizophrenia, the health care system, and health care providers are critical factors to consider in the development of targeted interventions to improve the physical health of this population.

Purpose

The purpose of this dissertation grounded theory study is to gain understanding of the experiences and mental health of Ugandan grandparents 50 years of age and older who provide primary care for grandchildren affected by HIV/AIDS.

Background

Despite the overall global decrease in AIDS-related deaths and HIV infections, sub-Saharan Africa remains the region most affected by the epidemic. In 2015, 23.5 million people were living with HIV in sub-Saharan Africa while an average of 800,000 people have died of AIDS-related causes. Uganda was reported to have had an estimated 28,000 adult deaths due to AIDS by 2015 that rendered approximately 660,000 children orphans to date (UNAIDS, 2016). Despite broad acknowledgement that in this HIV/AIDS era older adult caregivers are the backbone and safety net of the African family, very little research has explored the impact of this grandparental burden on the physical and mental health of this vulnerable population.

Methods

Using a grounded theory approach, semi-structured qualitative interviews were conducted with 32 grandparents recruited from the general population impacted by the HIV/AIDS epidemic. The one-on-one interviews were audio-recorded, transcribed, and analyzed using open, axial, and selective coding as well as reflexive and analytic memoing congruent with the methodology.

Findings

Study participant narratives described the caregiving burden as being financial, emotional, and physical although a few rewards were reported. In addition, the current study highlighted other experiences such as the described dimensions of loss and characterized the psychosocial distress related the caregiving role and other socio-economic stressors and the associated coping strategies. The mental health implications and explanatory model of this experiences were also described.

Implications

The study’s findings provide an extensive insight into the experiences of Ugandan grandparent–caregivers in the context of the HIV/AIDS epidemic. These insights can potentially inform clinicians, researchers, and policy makers who may seek explanatory models upon which to create care plans and design family-centered and community-based interventions such as childcare and respite care for these older grandparent–caregivers.

Background: Hearing loss is highly prevalent, especially among older adults. Left untreated, hearing loss is linked to negative outcomes, that affect both the person with hearing loss and the communication partner. Previous research has shown that hearing loss can negatively affect their physical and mental health, as well as their psychosocial functioning but the use of hearing aids can reduce these negative effects. The current longitudinal study aimed to investigate the potential effect of hearing aid use on psychosocial functioning in both people with hearing impairment and their communication partners in a community sample across one year.

Methods: Data were from 84 hearing impaired persons and 81 communication partners recruited as part of a longitudinal qualitative and quantitative study designed to examine the experiences of hearing impaired older adults and their communication partners over the course of one year. Participants completed the Short Form of the Hearing Handicap Inventory for the Elderly (HHIE-S), the emotional subscale of the Personal Assessment of Intimacy in Relationships (PAIR), and the 20-Item Short Form Survey (SF-20) at baseline and then again after intervals of three and 12 months.

Results: Hearing aid use was negatively associated with hearing handicap index scores for both participants with hearing loss (p < 0.0001) and communication partners (p < 0.0001) indicating hearing aid use reduced hearing handicap for both hearing impaired participants and communication partners. Hearing aid use was not associated with scores on the PAIR or SF-20 for either the participants with hearing loss or their communication partners.

Discussion: Hearing aid use reduced hearing handicap for both hearing impaired persons and their communication partners. Nurses can increase awareness and provide education about the negative consequences of untreated hearing loss for the hearing impaired person and their communication partner with the goal of facilitating earlier access to hearing aids.