Death and late-stage dementia in institutions : a cultural analysis

The first purpose of this study was to describe the deaths of fifteen nursing home residents with late-stage dementia. The devastating effect of dementia on a person has been called a ‘living death’ (Woods, 1989). The caring which occurs when someone is going through this process in a nursing home was recorded and analysed. In analysing this act of caring, the second purpose was to look for the origins of the structures and the sources of pressure that shaped the context and therefore helped determine the behaviour of the various groups under observation. These groups were residents and their relatives, the staff of the nursing home and the treating doctors. Before commencing observations and carrying out this study, an understanding needed to be developed of: the condition of dementia as it is perceived by health professionals and presented in the media; the institutions in which the majority of people with dementia end their days; the background and conditions of the staff who nurse in them; the models of care that guide and determine policies; and the conceptions of life and death which underpin relevant laws and moral standpoints. Accordingly, in part 1. chapter 1 the history, causes, pathology and effects of dementing conditions are examined. Relevant medical and lay literature including media influences are examined which pertain to the subject of death and dementia and nursing home care. The history of this institutional care is briefly examined together with the growth of the discipline of gerontological nursing. Chapter 2 discusses some of the effects of this history on present day care and the concept of emotional work being carried out within the present day aged care public policy regulations. The moral arguments surrounding illness and dying in Australian society today are briefly discussed. Chapter 3 describes the conceptual framework for the study, the ethnographic method that has been employed and an outline of critical theory as the basis for analysis. The chapter concludes by recounting the practical steps taken to arrange the field work, secure the consent of participants, record data and gather documents, and outlines the ethical considerations given to the undertaking of the study. Chapter 4 describes the context in which the study took place and the first tentative exploration of the culture from an etic perspective. Part 2 describes the death trajectories observed and raises some questions about alternative strategies that may have been considered within a different paradigm of caring. In chapter 5 the death trajectories of each of the fifteen residents in the study are described, each written with a particular emphasis to illustrate aspects of the culture of care that emerged through thematic analysis. Observations, comments and feelings from staff and family are wound in and around these case studies. Chapter 6 looks more closely at the impact of policy and institutional pressure on the milieu in which these deaths took place. Part 3 draws conclusions from the observations and makes suggestions for emancipatory change as viewed from the author's standpoint of critical ethnographic analysis. In the final chapter an argument is presented for policy change that leads a movement towards palliative care practices for people with late-stage dementia. Approaches to implementation of palliative care will need to take account of any expression by the resident such as an advanced directive, indicating a preferred approach to treatment in the period prior to death; a need for a better understanding of such issues as the significance of body breakdown, the manifestations of pain and electrolyte imbalances; the surrounding ethical complexities and shift in public opinion, and perhaps, most of ail, the culture of the institutions in which this dying will take place. A definition of late-stage dementia which might be used in determining patterns of care is set out. A discussion about changes in practice which relate lo communication with treating doctors, the administering of antibiotics, the relief of pain, the mobilisation of residents and the provision of food and water takes place in light of the evidence found. The discussion of these issues is raised in the form of debate. Each aspect needs more rigorous analysis and information so that evidence-based practice, rather than care which is value-laden and emotional, can be used when treatment decisions are made for people with late-stage dementia.

Within and against performativity : discursive engagement in adult literacy and basic education

The field of adult literacy and basic education (ALBE) has undergone dramatic changes in recent years with the advent of labour market programs, accreditation, competency-based assessment and competitive tendering for program funds. Teachers' working conditions have deteriorated and their professional autonomy has been eroded. ALBE has been increasingly instrumentalised to fulfil the requirements of a marketised economy and conform to its norms. The beliefs and value systems which traditionally underpinned the work of ALBE teachers have been reframed according to the principle of 'performativity' and the demands of the 'performative State' (Lyotard, 1984: 46, Yeatman 1994: 110). The destabilisation of teachers' working lives can be understood as a manifestation of the 'postmodern condition' (Lyotard 1984; Harvey 1989): the collapse of the certainties and purposes of the past; the proliferation of technologies; the impermanence and intensification of work; the commodification of knowledge and curricula; and the dissolving of boundaries between disciplines and fields of knowledge. The critiques of the modernist grand narratives which underpin progressivist and critical approaches to adult literacy pedagogy have further undermined the traditional points of reference of ALBE teachers. In this thesis I examine how teachers are teaching, surviving, resisting, and 'living the contradictions' (Seddon 1994) in the context of struggles to comply with and resist the requirements of performativity. Following Foucault and a number of feminist poststructuralist authors, I have applied the notions of 'discursive engagement' and 'the politics of discourse' (Yeatman 1990a) as a way of theorising the interplay between imposed change and teachers' practice. I explore the discursive practices which take place at the interface between the 'new' policy discourses and older, naturalised discourses; how teachers are engaged by and are engaging with discourses of performativity; how teachers are discursively constructing adult literacy pedagogy; what new, hybrid discourses of 'good practice' are emerging; and the micropractices of resistance which teachers are enacting in their speech and in their practice. My purpose was to develop knowledge which would support the reflexivity of teachers; to enrich the theoretical languages that teachers could draw upon in trying to make sense of their situation; and to use those languages in speaking about the dilemmas of practice. I used participatory action research as a means of producing knowledge about teachers' practices, structured around their agency, and reflecting their standpoint (Harding 1993). I describe two separate action research projects in which teachers of ALBE participated. I reflect on both projects in the light of poststructuralist theory and consider them as instances of what Lather calls 'within/against research' (Lather 1989: 27). I analyse written and spoken texts produced in both projects which reflect teachers' responses to competency-based assessment and other features of the changing context. I use a method of discourse mapping to describe the discursive field and the teachers' discursive practices. Three main configurations of discourse are delineated: 'progressivism', 'professional teacher' and 'performativity'. The teachers mainly position themselves within a hybridising 'progressivist /professional teacher' discourse, as a discourse of resistance to 'performative' discourse. In adapting their pedagogies, the teachers are in some degree taking the language and world view of performativity into their own vocabularies and practices. The discursive picture I have mapped is complex and contradictory. On one hand, the 'progressivist /professional teacher' discourse appears to endure and to take strength from the articulation into it of elements of performative discourse, creating new possibilities for discursive transformation. On the other hand, there are signs that performative discourse is colonising and subsuming progressivist /professional teacher discourse. At times, both of these tendencies are apparent in the one text. Six micropractices of resistance are identified within the texts: 'rational critique', 'objectification', 'subversion', 'refusal', 'humour' and 'the affirmation of desire'. These reflect the teachers' agency in making discursive choices on the micro level of their every day practices. Through those micropractices, the teachers are engaging with and resisting the micropractices and meanings of performativity. I apply the same multi-layered method of analysis to an examination of discursive engagement in pedagogy by analysing a transcript of the teachers' discussion of critical incidents in their classrooms. Their classroom pedagogies are revealed as complex, situated and eclectic. They are combining and integrating their 'embodied' and their 'institutional' powers, both 'seducing' (McWilliam 1995) and 'regulating' (Gore 1993) as they teach. A strong ethical project is apparent in the teachers' sense of social responsibility, in their determination to adhere to valued traditions of previous times, and in their critical self-awareness of the ways in which they use their institutional and embodied powers in the classroom. Finally, l look back on the findings, and reflect on the possibilities of discursive engagement and the politics of discourse as a framework for more strategic practice in the current context. This research provides grounds for hope that, by becoming more self-conscious about how we engage discursively, we might become more strategic in our everyday professional practice. Not withstanding the constraints (evident in this study) which limit the strategic potential of the politics of discourse, there is space for teachers to become more reflexive in their professional, pedagogical and political praxis. Development of more deliberate, self-reflexive praxis might lead to a 'postmodern democratic polities' (Yeatman 1994: 112) which would challenge the performative state and the system of globalised capital which it serves. Short abstract Adult literacy and basic education (ALBE) teachers have experienced a period of dramatic policy change in recent years; in particular, the introduction of competency-based assessment and competitive tendering for program funds. 'Discourse politics' provides a way of theorising the interplay between policy-mediated institutional change and teachers' practice. The focus of this study is 'discursive engagement'; how teachers are engaged by and are engaging with discourses of performativity. Through two action research projects, texts were generated of teachers talking and writing about how they were responding to the challenges, and developing their pedagogies in the new policy environment. These texts have been analysed and several patterns of discursive engagement delineated, named and illustrated. The strategic potential of 'discourse polities' is explored in the light of the findings.

Ethnography of housing : a conclusion

This paper is the final report of a research project spanning three years, exploring three field locations and capturing the stories of forty (plus) housing workers. Using an ethnographic research approach, this paper provides an account of how housing workers use language and stories to understand and make sense of their challenging and changing work. First hand accounts ('stories') about every day housing work frame the data in this paper, explaining how housing workers in Victoria have experienced and made sense of the shift from public housing as 'affordable housing for the working poor' to 'housing of last resort for the most vulnerable and needy members of the community'. Using a number of composite stories, this paper provides the reader with a glimpse into the work of public housing staff, transporting the leader from the relatively static world of policy and procedure to the more colorful world of tenants with 'high and complex' needs, 'wicked' problems, weary staff and the daily reality of organisational change.

A unique feature of this research is the comparison of how different workers use stories to build a range of 'socially constructed realities' around the housing work and its wicked problems. This paper compares and contrasts the socially constructed realities of frontline staff with the corresponding social realities of the managers at head office (and vice versa). This 'same problem, different perspective' approach allows the reader to better understand how the same problem is understood and approached in different ways, depending on the individual's organisational role, responsibly and authority. Using stories about 'working with problem tenants', 'collecting rental arrears from the poor and marginalised', 'maintaining old, neglected properties' and 'coping with organisational change', this paper illustrates how the shifting (and sometimes contradictory) construction of housing problems has meant that the organisation has long struggled to devise and implement sustainable remedies to these problems.

The following pages describe how the problems identified in the Housing Office Review (and experienced in the daily work of the 'modern day' housing worker) are simply a contemporary manifestation of 'age old public housing issues'. This paper describes and explains how housing staff have long used narrative to make sense of their often difficult work and ultimately, how they understand and experience a major process of operational policy change associated with the shift from 'public' housing to 'welfare' housing.

Health service systems and comorbidity: stepping up to the mark

Clients with co-occurring substance use and mental health disorders are not well served in traditional health care systems where specialist services offer segregated interventions and the client is left to negotiate required treatment across both systems. In recent years, policy change guiding the treatment of dual diagnosis in the United States, United Kingdom, Australia and elsewhere has triggered the development of diverse models of treatment, each of which function at different points on a continuum from serial to fully integrated care. This paper outlines key models and provides examples, while considering their potential for appropriately addressing the needs of this client group. Consideration is given to the benefits of an interaction between stepped care and the chosen model, as a means of enhancing care efficiency while retaining the focus on positive outcomes.

Ethnography of housing

This paper is the final report of a research project spanning three years, exploring three field locations and capturing the stories of forty (plus) housing workers. Using an ethnographic research approach, this paper provides an account of how housing workers use language and stories to make sense of their challenging and changing work. First hand accounts ('stories') about everyday housing work frame the data in this paper, explaining how housing workers in Victoria have experienced and made sense of the shift from public housing as 'affordable housing for the working poor' to 'housing of last resort for the most vulnerable and needy members of the community'. Using a number of composite stories, this paper provides the reader with a glimpse into the work of public housing staff, transporting the reader from the relativley static world of policy and procedure to the more colourful world of tenants with ' high and complex' needs, 'wicked' problems, weary staff and the daily reality of organisational change.

A unique feature of this research is the comparison of how different workers use their stories to build a range of 'socially constructed realities' around the housing work and its wicked problems. With a few exceptions (Saugeres, 1999, Howe, 1998, Clapham et al., 2000, Darcy, 1999) the voices of frontline staff are largley absent from contemporary housing literature. In this paper, I use the stories of frontline staff to build a comparative case study of the socially constructed realities for frontline staff and the corresponding realities of the managers at head office (and vice versa). This 'same problem, different perspective' approach allows the reader to better understand how the same problem is understood and approached in different ways, depending on the individual's organisational role, responsibility and authority. Using stories about 'working with problem tenants', 'collecting rental arrears from the poor and marginalised', maintaining old, neglected properties' and 'coping with organisational change', this paper illustrates how the shifting (and sometimes contradictory) construction of housing problems has meant that the organisation has long struggled to devise and implement sustainable remedies to these problems.

The following pages describe how the problem identified in the Housing Office Review (and experienced in the daily work of the 'modern day' housing worker) are simply a contemporary manifestation of  'age old public housing issues'. This paper describes and explains how housing staff have long used narrative to make sense of their often difficult work and ultimately, how they understand and experience a major process of operational policy change associated with the shift from 'public' housing to 'welfare' housing.

New governance, green planning and sustainability : Tasmania together and growing Victoria together

Bridgman and Davis(2000:91) have argued that ‘ideally government will have a well developed and widely distributed policy framework, setting out economic, social and environmental objectives’. This article compares and evaluates two such frameworks or plans, Tasmania Together and Growing Victoria Together, in terms of their potential to promote sustainability. It argues that they are very different exercises in new governance, aimed at reconnecting with community priorities and at redirecting macro-policy setting away from a preoccupation with economic priorities, respectively. Nevertheless, both plans have the capacity to ‘green’ state planning, in Tasmania in terms of more purposeful benchmarks, and in Victoria in terms of enhanced sustainability emphasis in the macro-policy setting. The article encounters tensions in its review of the plans between deliberation and planning, policy empowerment and policy progress, and policy institutionalisation and politicisation as means of achieving policy change. It finds that whilst Tasmania and Victoria are re-engaged states that are reinventing state policy, as yet they are failing to meet the governance challenges of sustainability.

Active citizenship : an empirical investigation

This paper reports on a study of what active citizenship means from the perspective of citizens who are active within third sector organisations. It is based on an empirical study involving 1,610 respondents across 11 towns in six countries. The study explored how active citizenship is manifested, by gathering data on attitudes towards social changes and the forms and practices of active citizenship. There are two major, and apparently contradictory themes emerging in the data. The first theme provides a portrait of active engagement, proactively, and sometimes oppositionally working for a better world. On the other hand, citizens by and large avoid active oppositional engagement in the political process. They prefer to work collaboratively with government and to work at the local level. This second theme can be understood as social maintenance, support for existing structures that facilitates community cohesion, while providing relief for the disadvantaged, oftenwith a conservative charity orwelfare orientation. Following thework of Touraine, the study revealed how citizens act at the local rather than the national level, and focus on concrete issues and interpersonal relations rather than political action aimed at wider policy change. While this form of citizenship action can reflect a conservative form of maintenance, it is equally a creative new form of association and mutual support.

Communication as coping; how staff working in public housing use narrative to understand their complex and sometimes challenging work.

This paper describes how ethnographic research was used to explore the communication practices of staff working organisation charged with the provision of low cost housing to some of the very poorest and most marginalised members of society in Victoria, Australia. This paper is concerned with how the narratives of the participants (that is, their ‘stories’) provides a very useful and potent insight into the daily life of staff working with people experiencing ‘multiple and complex needs’. The paper uses vignettes and case studies to illuminate the daily work of staff, sharing with the reader the things they see and hear and describing the complexity of the ‘wicked’ problems they face. More importantly, the research uncovered a number of narrative structures staff employ to understand and respond to these problems.

Regulation to create environments conducive to physical activity : understanding the barriers and facilitators at the Australian State Government level

Introduction Policy and regulatory interventions aimed at creating environments more conducive to physical activity (PA) are an important component of strategies to improve population levels of PA. However, many potentially effective policies are not being broadly implemented. This study sought to identify potential policy/regulatory interventions targeting PA environments, and barriers/facilitators to their implementation at the Australian state/territory government level.

Methods In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organisations (n = 40) to examine participants': 1) suggestions for regulatory interventions to create environments more conducive to PA; 2) support for preselected regulatory interventions derived from a literature review. Thematic and constant comparative analyses were conducted.

Results Policy interventions most commonly suggested by participants fell into two areas: 1) urban planning and provision of infrastructure to promote active travel; 2) discouraging the use of private motorised vehicles. Of the eleven preselected interventions presented to participants, interventions relating to walkability/cycling and PA facilities received greatest support. Interventions involving subsidisation (of public transport, PA-equipment) and the provision of more public transport infrastructure received least support. These were perceived as not economically viable or unlikely to increase PA levels. Dominant barriers were: the powerful ‘road lobby’, weaknesses in the planning system and the cost of potential interventions. Facilitators were: the provision of evidence, collaboration across sectors, and synergies with climate change/environment agendas.

Conclusion This study points to how difficult it will be to achieve policy change when there is a powerful ‘road lobby’ and government investment prioritises road infrastructure over PA-promoting infrastructure. It highlights the pivotal role of the planning and transport sectors in implementing PA-promoting policy, however suggests the need for clearer guidelines and responsibilities for state and local government levels in these areas. Health outcomes need to be given more direct consideration and greater priority within non-health sectors.

The game-changers: exploring radically transformational challenges confronting education business leadership

This paper highlights the radical and rapid changes occurring at all levels of education that are having a profound impact on educational leadership, governance, business and administration. These far-reaching transformations include: competition from a rapidly expanding unregulated private sector; the international impact of de-regulation; the demise of union power, secure education jobs, time-honored hours and working conditions; constant, rapid education policy change and the proliferation of open access technologies which are rendering physical education campuses less relevant or obsolete. The paper suggests that at this stage in history we are witnessing game-changing forces that are fundamentally altering educational provision, the nature of education work, the education workforce, educational outcomes, educational leadership, governance and business. Most importantly, it argues that educational leaders and education business managers need to be ready for them and more instrumental in policy debates arising in their wake. The paper concludes with ideas for responsive action from education business leaders.

Implications of radically transformational challenges confronting education business leadership

This paper highlights the radical and rapid changes occurring at all levels of education that are having a profound impact on educational leadership, governance, business and administration. These far-reaching transformations include: competition from a rapidly expanding unregulated private sector; the international impact of de-regulation; the demise of union power secure education jobs, time-honoured hours and working conditions; constant, rapid education policy change and the proliferation of open access technologies which are rendering physical education campuses less relevant or obsolete. The paper suggests that at this stage in history we are witnessing game-changing forces that are fundamentally altering educational provision, the nature of education work, the education workforce, educational outcomes, educational leadership, governance and business. Most importantly, it argues that educational leaders and education business managers need to be ready for them and more instrumental in policy debates arising in their wake. The paper concludes with ideas for responsive action from education business leaders.

Cost effectiveness of childhood obesity interventions: Evidence and methods for CHOICES

INTRODUCTION: The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE). METHODS: Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015-2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed. RESULTS: Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue. CONCLUSIONS: The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money.

Modelling a helicopter training continuum to support system transformation

his study investigates the role of system dynamics (SD) modeling to support strategic decision making for an aviation training continuum that is going through major change. The Australian helicopter training continuum (HTC) is currently undergoing transformation, with restructure and consolidation of training schools and training platforms across multiple services. In this research, we introduce a novel SD-based HTC simulation architecture to facilitate the discovery of relationships between student and instructor development and flow dynamics. The proposed simulation architecture employs hybrid push – pull flow control to quantify transience and estimate recovery time after a policy change or disturbance. This architecture allows for multiple student and instructor types, and their respective intake levels and pass rates. Here the instructor variables include availability, specialization and experience. Enos (2011) successfully explored the application of SD modeling to understand the behavior for combat aviation training in an individual school. This research employs a similar modeling philosophy, but takes a higher level view of the system by looking across multiple training schools, which introduces complexity due to pooling, latency and the amplification of affects across the system. The ability to identify causal relationships allowed stakeholders to develop a deeper understanding of the underlying systemic problems, such as delayed transitions between schools and instructor shortages, whilst the hybrid “push-pull” design allowed us to quantify the pooling of students between schools.

President Rouhani and Iran’s ‘Woman Question’ after one year in office

Is the Islamic Republic capable of accommodating gender reform? What does the election of reformist President Hassan Rouhani mean for the country’s women? And after one year in office, has his government offered a meaningful response to the ‘woman question’? This paper examines the socio-political climate around women and their position in Iranian society inherited by the Rouhani administration, and analyses the extent to which Rouhani has the authority to oversee real policy change on women’s status. Through a critical review of Rouhani’s first year in office, the author argues that there are some promising signs of change, but these are up against a culture of patriarchy that is entrenched amongst Iran’s political and clerical elite, whose view of women is that of the homemaker and caregiver, with limited public agency.

A proposal for unemployment insurance

The problems of entrenched high unemployment in Australia, and the need to improve the support given to people who are affected by unemployment, require new thinking and new ideas in order to bring about policy change.Therefore, Jobs Australia commissioned this research paper to ask Professor Andrew Scott to elaborate on his analysis of the possible relevance to Australia of the Danish approach to employment security which he expounded in his 2014 book, Northern Lights.In particular, we asked Professor Scott to outline practical steps which Australia might consider taking which are feasible and realistic: cutting ‘with the grain’ of Australia’s own distinctive institutional and policy approaches in order to shape new, better-designed policies which might reduce the poverty and uncertainty now faced by so many people in this country.It is very important that Australia now learn from overseas, and not only look at English-speaking countries in which, after all, in many cases, the problems are worse than ours in terms of higher inequalities and larger numbers of long-term unemployed.It is appropriate, in a true spirit of embracing globalisation, to look at the best performing nations in terms of tackling unemployment, and what may possibly be learned from them to apply in the challenges we face here in Australia.Jobs Australia is the national peak body representing not-for-profit organisations that help disadvantaged people find work.We are the largest network of employment and related service providers in Australia and we are funded and owned by our members.I am pleased to endorse the thrust of the arguments put forward in this paper and for Jobs Australia to publish it in this format in order to open up debate and to seek more engagement from key policy-makers with the ideas presented here.