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In the context of global ageing societies, there are few challenges to the underlying assumption that policies should promote functional health and independence in older people and contain the costs of care. This important book offers such a challenge. It provides a critical analysis of the limitations of contemporary policies and calls for a fuller understanding of the relationship between health and care throughout the life-course. Located within the tradition of the feminist ethic of care, the book provides a fresh insight into global policy debates and the impact that these have on people's experiences of ageing. Including international evidence on health inequalities, health promotion and health care, this book will be of interest to a range of social scientists, particularly specialists in gerontology and social policy.

The fourth age remains a poorly understood phenomenon and there is a lack of understanding of the perceptions of those who might be considered to be living in it. This article draws on findings from a study of dignity in later life which examined the day-to-day experiences of participants who were in need of support and care because of failing health. It discusses their accounts of the changes to their sense of self and their identity that came about as a result of their ageing and health problems and looks also at the ways in which the support and care they received helped to shape their adjustment to those changes. The accounts given by participants reveal a great deal about the physical, mental and emotional effort entailed in maintaining a sense of self and highlight the essential role played by social relationships in the maintenance of identity. These findings are analysed by reference to emerging theories of the fourth age.

Purpose: The process of individual ageing in the context of a care environment is marked by continuity and change. It is shaped by individual, health-related factors as well as by diverse social and environmental factors, including characteristics of the places where older people live. The aim of this paper was to explore how longitudinal qualitative research, as a research method, could be used to explore older people's changing care needs. Methods: The study used a longitudinal design to examine how the care and support needs of residents and their expectations of services developed over time and how these were influenced by changes in the organisation of their housing as well as in the make-up of the resident population. Residents were interviewed on four occasions over 20 months. Results: The study highlighted the complex ways in which some participants proactively managed the care and support they received, which we argue would have been difficult to discern through other methods. Conclusion: The study adds to the growing evidence base that supports the use of qualitative longitudinal research; the approach enables the researcher to capture the diverse and mutable nature of older people's experiences at a time of profound change in their lives.

Introduction: Faced with rising numbers of older people in need of care and restrictions on public expenditure in the UK, extra care housing (ECH) has been hailed as an integrated model of housing with care that allows older people to live independently, while also having access to care and support if required. Despite the proposed benefits of ECH, however, little is known about how responsive it is to the needs of older people as their care needs change. Theory/Methods: This presentation reports on findings from the ECHO project, which explored the perspectives and experiences of those living and working in ECH settings. Longitudinal qualitative research was undertaken at 4 ECH settings (including one dementia-specialist scheme), based in 2 areas, over the course of 2 years. Residents were interviewed on 4 occasions to explore how their care needs and experiences of ECH changed over time. Managers were interviewed twice, at the beginning and end of the study, and care workers were interviewed on one occasion. Results: Residents appreciated the flexibility in the way that care was provided and felt that the ECH model allowed them some control over when and how their care was delivered. Some residents, care workers and managers reported an increase in care needs amongst people moving into ECH and amongst existing residents as they aged in place. Interviews with care workers revealed that their work was organised in a time/task manner. This resulted in frustration for some care workers who felt unable to provide care in a flexible and personalised way. Some care workers found ways to compensate for this approach by providing ‘favours’, doing tasks beyond their role. Discussions: The organisation of work in the 4 ECH schemes imitated patterns of work at some traditional care homes and it appeared that there was very little slack in the system. This is problematic given that there is an expectation of ECH to meet the changing care needs of residents in a timely and responsive manner. Such problems appear to be exacerbated by the changing context of ECH which means that the population whom it serves now has higher and more complex needs. Conclusions (including key findings): ECH’s integrated model of housing and care has the potential to support quality of life for older people, including those living with dementia. However, while the ECH model promises to allow for increased flexibility and a more personalised approach to care delivery, cost saving forms of work organisation can undermine this approach. Lessons learned: Longitudinal research is a beneficial way to examine how older people’s care needs are responded to in integrated housing and care environments. Limitations: Though a longitudinal approach allowed us to consider how participants’ experiences altered over time, and in relation to contextual change, this approach was not as effective with residents living in a dementia-specialist ECH scheme. Suggestions for future research: Further research is required to establish whether ECH is the most appropriate form of integrated housing and care for older people living with dementia.

The feminist ethics of care present a challenge to social workers to re-assess not only the place of care within professional social work practice but also the way in which concepts of justice, autonomy and rights are conceptualized and ageing is understood. In this article, the arguments for an ethics of care are considered in relation to social work practice with older people. It is argued that the feminist ethics of care offer useful insights that are relevant to the practice of social work, particularly within contemporary demographic, economic, political and organizational contexts, all of which have made the task more complex and confusing.

Purpose: This study was designed to collect and compare nurse staffing standards and staffing levels in six counties: the United States, Canada, England, Germany, Norway, and Sweden. Design: The study used descriptive information on staffing regulations and policies as well as actual staffing levels for registered nurses, licensed nurses, and nursing assistants across states, provinces, regions, and countries. Methods: Data were collected from Internet searches of staffing regulations and policies along with statistical data on actual staffing from reports and documents. Staffing data were converted to hours per resident day to facilitate comparisons across countries. Findings: We found wide variations in both nurse staffing standards and actual staffing levels within and across countries, although comparisons were difficult to make due to differences in measuring staffing, the vagueness of standards, and limited availability of actual staffing data. Both the standards and levels in most countries (except Norway and Sweden) were lower than the recommended levels by experts. Conclusions: Our findings demonstrate the need for further attention to nurse staffing standards and levels in order to assure the quality of nursing home care. Clinical Relevance: A high quality of nursing home care requires adequate levels of nurse staffing, and nurse staffing standards have been shown to improve staffing levels. Journal of Nursing Scholarship, 2011; XX:X, XXX–XXX. ©2011 Sigma Theta Tau International.

This paper focuses on the circumstances of death and dying in old age. It considers the ways in which social policies and social gerontology reflect the values of independence, autonomy and citizenship, and it considers the implication of these values for older people who are dependent on others for care and support at the end-of-life. It discusses the complexity of the relationship between ageing and dying, by exploring recent research from the fields of social gerontology and the sociology of death and dying. Arguing that a long-term perspective is required to understand fully the circumstances of older people's deaths, it analyses the third age/fourth age dichotomy as a conceptual model. The task of developing knowledge about the links between ageing and dying requires consideration of moral and ethical principles. The article examines the conceptual frameworks developed by feminists who argue for an ethics of care as a central analytic referent in social policy. The feminist ethics-of-care approach provides a powerful critique of the moral framework of independence and autonomy as characterised in contemporary policies and practices. Feminist ethicists argue that the inter-relatedness of human beings and the importance of the social context have been overlooked in the preoccupation with individual rights – as reflected more generally in policies and social life. It is argued in the paper that the need for care at the end-of-life highlights these shortcomings. The feminist ethics of care has considerable potential to illuminate our understanding of dependency and care, and to generate both new approaches to policy and practice in health and social care and theoretical perspectives in gerontology.

Extra-care housing (ECH) has been hailed as a potential solution to some of the problems associated with traditional forms of social care, since it allows older people to live independently, while also having access to care and support if required. However, little longitudinal research has focused on the experiences of residents living in ECH, particularly in recent years. This paper reports on a longitudinal study of four ECH schemes in the United Kingdom. Older residents living in ECH were interviewed four times over a two-year period to examine how changes in their care needs were encountered and negotiated by care workers, managers and residents themselves. This paper focuses on how residents managed their own changing care needs within the context of ECH. Drawing upon theories of the third and fourth age, the paper makes two arguments. First, that transitions across the boundary between the third and fourth age are not always straightforward or irreversible and, moreover, can sometimes be resisted, planned-for and managed by older people. Second, that operational practices within ECH schemes can function to facilitate or impede residents’ attempts to manage this boundary.

In the context of global ageing societies, there are few challenges to the underlying assumption that policies should promote functional health and independence in older people and contain the costs of care. This important book provides such a challenge.