Structuring unequal relations: role trajectories in informal dementia care

Transitions into informal care roles are associated with various characteristics, for example gender and geographic proximity, but such associations are insufficient to explain role delegation, overlooking the interpersonal structure–agency nexuses that constitute role trajectories. This paper explores unequal role delegation within 7 families affected by dementia, presenting data from interviews with 7 people with dementia and 26 carers living in the community in the United Kingdom. Two key care roles are identified: the relatively un‐involved role of peripheral actors and the lynchpin role of main carers who take on most of the care tasks. These roles emerge from negotiations around a range of extraneous factors that collectively comprise cumulative baggage, including historic conflicts and childcare commitments. The unequal distribution of care reflects widely noted demographic associations with role delegation, but is enacted and justified through the interpersonal negotiation of personalised meanings regarding individual circumstances and suitability. Though deeply personal when taken at face value, these meanings imbibe sociocultural norms and political economies of care to structurally position family members in relation to each other and signpost appropriate candidates for caring roles, even before such care is required.     

Cognitive Informatics, Distributed Representation and Embodiment

This paper is a revised and extended version of a keynote contribution to a recent conference on Cognitive Informatics. It offers a brief summary of some of the core concerns of other contributions to the conference, highlighting the range of issues under discussion; and argues that many of the central concepts and preoccupations of cognitive informatics as understood by participants--and others in the general field of computation--rely on ill-founded realist assumptions, and what has been termed the functionalist view of representation. Even if such ideas--albeit in a revised form -- can be defended, there must be a more extensive engagement with the literature and issues outside the confines of the computing and computational orthodoxy.     

Rules and resources: a structuration approach to understanding the coordination of children's inpatient health care

AIM: This paper presents findings from a multi-method study exploring the process of care coordination in children's inpatient health care. BACKGROUND: Existing work on care coordination is typified by "black-box" type studies that measure inputs to and outcomes of care coordination roles and practices, without addressing the process of coordination. METHOD: Using questionnaires, interviews and observation to collect data in multiple sites in the United Kingdom and Denmark between 1999 and 2005, the study gathered the perceptions of staff and compared these with observed practice. Giddens' structuration theory was used to provide an analytical and explanatory framework. FINDINGS: Current care coordination practice is diverse and inconsistent. It involves a wide range of clinical and non-clinical staff, many of whom perceive a lack of clarity about who should perform specific coordination activities. Staff draw upon a wide range of different material and non-material resources in coordinating care, the use of which is governed by largely tacit and informal rules. CONCLUSIONS: Care coordination can be usefully conceptualized as a "structurated" process--one that is continually produced and reproduced by staff using rules and resources to "instantiate" or bring about care coordination through action. Potentially negative implications of this are manifested in diversity and inconsistency in care coordination practice. However, positive aspects such as the opportunity this provides to tailor care to the needs of the individual patient can be realized.     

The NIH's slow response to the AIDS epidemic and the dismissal of Pasteur's contributions: Learning from history

The National Institutes of Health's (NIH) slow response to the AIDS epidemic in the early 1980s led to deaths and missed opportunities to stop the spread of the disease. In addition, the NIH systematically diminished the contributions of the scientists at the Pasteur Institute who discovered HIV and produced a superior AIDS test. I analyze these events by applying three social theories to the global response to the epidemic. Structuration, interorganizational learning, and negotiated order theories shed light on (1) the delay by the NIH in providing grants for AIDS research, (2) the inability of the NIH to learn about the epidemic from the Centers for Disease Control and Prevention, and (3) the NIH's dismissal of AIDS discoveries by a team of Pasteur scientists. Lastly, I give suggestions to enable effective cooperation among health agencies to better respond to future epidemics.     

Improving socially constructed cross‐cultural communication in aged care homes: A critical perspective

Cultural diversity between residents and staff is significant in aged care homes in many developed nations in the context of international migration. This diversity can be a challenge to achieving effective cross‐cultural communication. The aim of this study was to critically examine how staff and residents initiated effective cross‐cultural communication and social cohesion that enabled positive changes to occur. A critical hermeneutic analysis underpinned by Giddens’ Structuration Theory was applied to the study. Data were collected by interviews with residents or their family and by focus groups with staff in four aged care homes in Australia. Findings reveal that residents and staff are capable of restructuring communication via a partnership approach. They can also work in collaboration to develop communication resources. When staff demonstrate cultural humility, they empower residents from culturally and linguistically diverse backgrounds to engage in effective communication. Findings also suggest that workforce interventions are required to improve residents’ experiences in cross‐cultural care. This study challenges aged care homes to establish policies, criteria and procedures in cross‐cultural communication. There is also the challenge to provide ongoing education and training for staff to improve their cross‐cultural communication capabilities.     

Systems,economics, and neoliberal politics: Theories to understand missed nursing care

The phenomenon of missed nursing care is endemic across all sectors. Nurse leaders have drawn attention to the implications of missed care for patient outcomes, with calls to develop clear political, methodological, and theoretical approaches. As part of this call, we describe three structural theories that inform frameworks of missed care: systems theory, economic theory, and neoliberal politics. The final section provides commentary on the strengths and limitations of these three theories, in the light of structuration theory and calls to balance this research agenda by reinstating nurse agency and examining the interactions between nurses as agents and the health systems as structures. The paper argues that a better understanding of variations in structure–agency interaction across the healthcare system might lead to more effective interventions at strategic leverage points.     

Structure et déstructuration à la sénescence

After having defined the structure of personality, the author examines its destiny late in life. If certain structures keep up in old age such as well internalised neuroses, others end up in actual neuroses or undergo a massive destructuring process, as in Alzheimer's disease. Using the psychosomatic theory of the Paris School (Pierre Marty), which emphasizes trauma and fixations, the author inquires into these different clinical configurations as well as into their possible relations.