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Knowledge seeking patterns of care aides in residential care facilities Gauthier, Renée Lesley 2018

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   KNOWLEDGE SEEKING PATTERNS OF CARE AIDES IN  RESIDENTIAL CARE FACILITIES  by Renée Lesley Gauthier BScN, The University of Victoria, 2006    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING in The College of Graduate Studies    THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan)  April 2018  © Renée Lesley Gauthier, 2018   ii  The following individuals certify that they have read and recommend to the College of Graduate Studies for acceptance, a thesis entitled:  KNOWLEDGE SEEKING PATTERNS OF CARE AIDES IN RESIDENTIAL CARE FACILITIES   Submitted by Renée Lesley Gauthier in partial fulfillment of the requirements of the degree of  Master of Science in Nursing.  Dr. Elizabeth Andersen, School of Nursing Supervisor  Dr. Colin Reid, School of Health and Exercise Sciences Supervisory Committee Member  Dr. Deanne Taylor, School of Nursing Supervisory Committee Member  Dr. Sabre Cherkowski, Faculty of Education External Examiner   iii  Abstract Background: Care aides represent the largest demographic of residential care facility staff, and provide the greatest amount of direct care hours to residents, yet little is known about the knowledge seeking patterns of this group. Understanding the patterns of how, why, when and where care aides seek information to perform their duties is important for employers, policy makers and other stakeholders when designing training programs and planning knowledge sharing strategies. Purpose: To explore the knowledge seeking patterns of care aides who provide care to residents in residential care facilities. Sample/Methods: Semi-structured interviews regarding knowledge seeking patterns in the workplace were conducted with eight care aides employed in three residential care facilities in British Columbia. The interviews were transcribed verbatim and analyzed using the Braun and Clarke method of Thematic Analysis. Key Findings: Five themes were identified: What I Read, What I Hear, What I Already Know, When I Have Time, and Why I Seek. Time constraints and familiarity with residents were overarching concepts throughout the themes. The concept of reporting as knowledge seeking was also revealed, in relation to care aide self-identities as observers and reporters. Implications: Care aides should be encouraged to seek knowledge about residents and their care requirements. Training programs to enhance care aide communication skills and shift self-identity to the role of knowledge seekers are recommended. Dedicated time for knowledge seeking during work hours should be provided to care aides, and practices should be reviewed to optimize care aides consistently receiving accurate information about their residents without delays or obstructions in the communication chain.    iv  Lay Summary  Care aides represent the largest group of staff in residential care facilities (nursing homes). They provide up to 80% of the hands-on care to residents, more than any other health care professional, including nurses. The purpose of this study was to learn how care aides seek knowledge to provide care for their residents. The researcher interviewed eight care aides, then analyzed the interviews using Thematic Analysis (a step-by-step process that includes reviewing the data in detail and searching for the underlying meanings or common ideas, called themes). Five themes were identified in this study. Care aide knowledge seeking patterns should be considered when designing workplace practices, training curricula and policies. In future, researchers should investigate care aide knowledge sharing practices and how these practices influence knowledge seeking for the purpose of meeting the needs of workers and residents.    v  Preface This thesis reports on the results of an independent qualitative study that used thematic analysis to collect and interpret data gathered through interviews. I recruited the participants, completed the data collection, analyzed the data and wrote this thesis with guidance and input from my supervisor, Dr. Elizabeth Andersen, and my committee members, Dr. Colin Reid and Dr. Deanne Taylor. Ethical approval for this study was provided by the UBC Behavioural Research Ethics Board, in harmonized review with the Interior Health Authority. The certificate number for this approval is H17-01299.   vi  Table of Contents Abstract ………………………………………………………………………………………… iii Lay Summary ……………………….………………………………………………………….. iv Preface ………………….……………………………………………………………………….. v Table of Contents ………………………………………………………………………………. vi List of Tables …………………………………………………………………………………… xii List of Figures …………………………………………………………………………………. xiii Acknowledgements …………………………………………………………………………..… xiv Dedication ………………………………………………………………………………………. xv CHAPTER 1: INTRODUCTION …………………………………………………………..…... 1      Background …………..…………………………….……………………………………..…... 1      Purpose ……………...………………………………………………………………..……….. 4      Significance …………………...………………………………………………………….…… 4 CHAPTER 2: LITERATURE REVIEW ………………………………………………..……... 6      Search Strategy …………..……………………………………………………….……..……. 6      What is Known About Care Aide Preferences for Knowledge Sources …………..…….... 7      A Preference for Informal Knowledge Sources ………...………………………………..…. 7      What is Known About Care Aide Patterns of Knowledge Utilization …….……...……..... 9 Theoretical Knowledge Utilization ………………………………………………..……… 9 Informal Knowledge Utilization ………………………………………….………..……. 10 Formal Knowledge Utilization …………………………………………..………………. 11      Evidence based practices ………………...………………………….………..………. 11      Care plans ……………………………………...…………………………………..…. 12      Efforts designed to enhance formal knowledge utilization …………..……...……….. 12 vii  Selection and Evaluation of Knowledge ………..……………………………………….. 13 The Influence of Workplace Culture on Knowledge Seeking and Utilization ……….…. 14 Knowledge Sources and Knowledge Utilization of Professional Nurses ……..………… 14      Concluding Remarks ………………...……………….…………………………………….. 15 CHAPTER 3: METHOD …………………………..…………………………………………... 17      Reflexivity ………...………………………………………….……………………………… 17      Setting ………...……………………………………………..……………………………….. 19      Participant Sample …………...………………………………..……………………………. 20 Inclusion/Exclusion Criteria ……………………………………..………………………. 20 Sample Size …………………………………………………………..………………….. 20 Recruitment Process ……………………………………………………..………………. 22      In person recruitment …..……………...…………………….……………………….. 22      Poster recruitment ………………...…..………………………………….…………... 23 Participant Characteristics ………………………………………………………..……… 23      Data Collection ……………………………...………….…………………………………… 25 Potential Risks ……………………………………………..…………………………….. 26      Procedures for protecting against or minimizing any potential risks ……..………….. 26 Consent Process ………………………………………………………………….……… 30 Interviews …………………………………………………………………………..……. 31 Data Management ……………………………………………………………….………. 31      Data Analysis and Interpretation ……………………...………………………….……….. 32 Phase 1- Familiarizing Oneself with the Data ……………………..…………………….. 33 Phase 2- Generating Initial Codes …………………………………………..…………… 34 Phase 3- Searching for Themes ………………………………………………..………… 34 viii  Phase 4- Reviewing Themes …………………………………………………..………… 35 Phase 5- Defining and Naming Themes …………………………………………..……... 35      Rigour ………………...…………………………………………………..……………..…… 36 CHAPTER 4: FINDINGS ……………………………………………………………….…….. 37      What I Read ……...……………………………………………………………………..…… 40 Preferred Documentation ………………………………………………………..………. 42      Progress notes ……………...………………………………………………..……….. 42      ADL sheets ………………………………………………………………….……….. 43 Usefulness …………………………………………………………………….…………. 44      Technology ………...………………………………………………………..………... 44      Locations ………………...………………………………………………..………….. 46 Summary of What I Read ……………………………………………………..…………. 47      What I Hear ……………………………...……………………………..……………….…... 47 Team ………………………………………………………………..……………………. 48      Other care aides ……...………..…………………………………..………………….. 49      Casual team members ……….....…………………………………….………………. 50      Team communication ……………………...………………………..………………... 52 Power and Relationships ………………………………………………..……………….. 53       Care aide voice …………...……..…………………………………..………………... 55       Staff relationships ……………...……………………………………..…….………… 58 Residents and Families ……………………………………………………..……………. 59       Residents ……………………………………..….………………….………………... 59       Families …………………….……………………..……………………..…………… 61 Summary of What I Hear ………………………………………………….…………….. 63 ix       What I Already Know ………………..…….…………………………………..…………… 64 Training ……………………………………………………………………..…………… 65 Experiences ………………………………………………………………….…………... 66    Standard practices …………………………………………………………..…………. 67 Creative Genius ………………………………………………………………..………… 70 Summary of What I Already Know …………………………………….……………….. 71      When I Have Time …………..………………….………………………….……………….. 72 Available Time ……………………………………………………………..……………. 73    Finding time ……………………..………………………………………..…………… 75 Timing …………………………………………………………………………..……….. 76    After hours …………………………………………….…………………….………… 77    Admissions …………………………………….………………………………..……... 79    Changes ………………………….……………………………………………..……… 81 Fluctuations …………………………………………………………………..….. 85 Summary of When I Have Time ……………………………………………..………….. 86      Why I Seek ……………………………………………...……………………..…………….. 88 Natural Caregivers ……………………………………………………….……………… 88 Preparedness ………………………………………………………………..……………. 90 What is Right? …………………………………………………………..……………….. 92 Summary of Why I Seek ………………………………………………..……………….. 95 CHAPTER 5: DISCUSSION …………………….……………………………………………. 97      Familiarity …………………………………….…………...………………………………... 97      Figuring it Out …………………………………..………...………………………………… 98      Preferred Sources ………………………………..…...……………………………………... 99 x       Not Enough Time …………………………….…...……………………………………….. 102      Reporting as Knowledge Seeking ………...….…………………………………………… 102 Assigning and Delegating …………………….………………………………………... 103 Reporting and Power Structures ………………..………………………………………. 104 Giving Report ……………………………………………..……………………………. 107      Practice Implications ………..…………………………………………….………….…… 109 Workplace Practice …………………………………………………………….………. 110 Training …………………………………………………………………………..…….. 110 Policy ………………………………………………………………………………..….. 112      Implications for Future Research ………...……..……………………………………..…. 113      Limitations ……………………………...………………………………………………..… 115      Conclusion …………………………...…………………………………………………..…. 118      References ………………………..…………………………………………………..…….. 119 APPENDICES ………………………………………………………………………….……... 131      Appendix A: Search Terms and Results ...………………………………………..……… 132      Appendix B: Recruitment Handout ………………..……………………………..……… 135      Appendix C: Recruitment Poster ……………………..……………………………..…… 136      Appendix D: Participant Demographics and Characteristics Collection Instrument .... 137      Appendix E: Information Letter and Consent Form ………………………...………..… 139      Appendix F: Transcriptionist Confidentiality Agreement ……...………..……………... 143      Appendix G: List of Pseudonyms ………………………………..………..……………… 144      Appendix H: Guiding Questions ………………………………..…………...……………. 145      Appendix I: Notes from Phase 1 …………………………………..………..…………….. 146      Appendix J: Initial Codes Phase 2 ……………………………..…………...…………….. 150 xi       Appendix K: Mind Map Phase 3 ………………………………..…………..……………. 151      Appendix L: Mind Map Phase 4 ……………………………..………...…………………. 152         xii  List of Tables Table 1: Search Strategy ……………………………………………………………………...…. 6 Table 2: Average Sample Size of Similar Qualitative Studies ………………………….…..…. 21 Table 3: Participant Characteristics ……………………………………………………...…….. 24 Table 4: Summary of Themes ……………………………………………………………...…... 38 Table 5: Glossary …………………………………………………………………………...….. 39                   xiii  List of Figures Figure 1: Thematic Map …………………………………………………………………...…... 38 Figure 2: Traditional Reporting Structure ………………………………………………...….. 105 Figure3:  Alternative (Contemporary) Reporting Structure ………………………….…...….. 106                      xiv  Acknowledgements  I would first like to acknowledge the study participants for speaking with me about their experiences. Without the openness and kindness of these individuals, this study would not have been possible. Thank-you, and may this work honour your stories. I would also like to thank the managers and administrators of the participating residential care facilities for their hospitality and their support for academic research.  I would like to thank my committee members, Dr. Colin Reid and Dr. Deanne Taylor, for their direction in this project. Your insightful questions and guidance were invaluable to the production of this work. And I am incredibly grateful for the contributions and mentoring offered by my supervisor, Dr. Elizabeth Andersen throughout this process. With a critical eye and a gentle manner you helped me to craft this thesis from conception to completion. Dr Andersen, I truly cannot thank you enough for your thoughtful editing and the genuine care that you have extended to me.  I would like to thank my employer for providing me with the flexibility to attend lectures and complete my thesis. Since the beginning of this program I have received only encouragement and generosity from my managers, supervisors and colleagues along the way.  Finally, I would like to thank my friends and family who have helped me to stay focussed in my pursuit of this goal. I am blessed to have had the earnest backing of my mother, both morally and practically, in the creation of this work. Thank-you, Mom, for showing me the values of determination and patience. To those who have graciously provided me quiet spaces, warm drinks and an abundance of wisdoms, and for those who have persisted in cheering and heartening me as I became swept away in this journey, from the bottom of my heart, I thank you.    xv  Dedication        À les DeSaule 1  CHAPTER 1: INTRODUCTION Background Care aides represent the largest demographic of health care staff in residential care facilities, and provide more direct care hours to persons living in residential care facilities than any other health care practitioner group (Berta, Laporte, Deber, Baumann, & Gamble, 2013; British Columbia Ministry of Health, 2017; Caspar, 2014). Although care aides make up the bulk of the workforce in residential care facilities, little is known about the patterns of their knowledge seeking.   The BC Care Aide and Health Worker Registry defines care aides as “frontline care providers in a variety of institutional and community settings including home support agencies and residential care facilities.” (2018).  They are unregulated, unlicensed, non-professional workers, operating globally under the designations “nursing assistant”, “aged care assistant”, “long-term care aide”, “personal care attendant”, “residential care aide”, “health care assistant” and other titles. By law in British Columbia care aides must work under the supervision and direction of regulated, licensed, professional nurses (BC Care Aide and Health Worker Registry, 2018), a title reserved for Nurse Practitioners and Registered Nurses (Health Professions Act: Nurses [Registered and Nurse Practitioners] Regulation, 2016), Licensed Practical Nurses (Health Professions Act: Nurses [Licensed Practical] Regulation, 2015) and Registered Psychiatric Nurses (Health Professions Act: Nurses [Registered Psychiatric] Regulation, 2015). Residential care facilities provide accommodation, meals and care to persons with physical or developmental disabilities (British Columbia Ministry of Health, 2018). “Nursing homes”, “long-term care facilities”, “elder homes”, and “homes” for the aged are other common terms for residential care facilities. They range in size from small group homes to large-scale buildings, and vary in specialties such as young-adults, dementia, acquired brain injury or complex 2  behaviours. Persons who live in residential care facilities are known as residents (Community Care and Assisted Living Act, 2002), and in British Columbia, facilities with three of more residents must be licensed and inspected (Community Care and Assisted Living Act: Residential Care Regulation, 2016). In this study, all care aides and nurses referred to both in the literature and the data set are persons working in residential care facilities, unless otherwise specified. Recent estimates indicate that care aides provide 80% or more of the hands-on care for residents (Berta, Laporte, Deber, Baumann, & Gamble, 2013; Caspar, 2014), yet there are no federal standards in Canada for care aide training. Training programs vary in length and content across provinces. According to their recruitment websites, these programs range from upwards of thirty-three weeks (Gateway College, 2016), down to seventeen weeks in length (Rosewood College, 2014). Although British Columbia now has the BC Care Aide and Community Health Worker Registry, which includes a list of recognized training programs, the registry is not a regulatory body. The purpose of the registry is to protect the public by tracking disciplinary actions, including suspensions and terminations, of care aides. Prior to the registry, unsafe or unethical workers were able to move from employer to employer, without any forwarded record of malpractice incidents or terminations occurring in their previous workplace.  Traditional dominate perspectives of care aides are that they take direction from nurses to complete prescribed tasks. Despite the hierarchical relationship with nurses, care aide roles are evolving to include expanded job duties and self-directed decision making (Andersen & Spiers, 2015; Berta et al., 2013; Estabrooks, Squires, Carleton, Cummings, & Norton, 2015; Hewko et al., 2015). With the rising complexity of residents and high ratios of residents to staff, every member of the team must be relatively self-sufficient to meet the needs of the individuals under their care. It is important that care aides are prepared to engage in knowledge seeking as a means of being well informed to do their work.  3  Information refers to the facts, details and particulars of a topic or concept while knowledge is the cumulative information that care aides require to do their work. Knowledge includes training in the skill sets required to perform tasks, information regarding resident medical and mental health conditions that may impact care, resident personal preferences and abilities, risks and measures to promote safe work. The particular knowledge, or information, that is required varies dependent on the particular resident and context. Throughout this thesis both terms, information and knowledge, are used interchangeably.  At times when care aides recognize a gap in knowledge that is impacting or impeding their ability to provide high quality, safe, care, they may attempt to acquire that knowledge. Knowledge seeking captures all activities that care aides engage in to attain the knowledge they believe is required to do their work. Asking people questions, researching on the internet, reading documents, conducting informal trials or experiments and self-reflection are examples of possible knowledge seeking activities.   Care aides’ diverse job duties, skill sets, and training make it difficult for researchers to capture the essence of their intuitive, meditative, scientific, or experiential sources of knowledge and methods of knowledge seeking. Previous research has determined that care aides prefer certain informal knowledge sources, such as verbal conversations and experiences, over formal sources including documentation and training, and that care aides exhibit patterns in the way they utilize knowledge when they provide care to residents (Caspar, 2014; Furåker & Nillson, 2009; Estabrooks et al., 2015; Janes, Sidani, Cott, & Rappolt, 2012; Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015; Rasin & Kautz, 2007). In this study, knowledge seeking patterns is as a holistic concept that includes why the knowledge is sought (for what purpose and in response to what factors); when the knowledge is sought (immediate, delayed, or restricted to certain 4  contexts); who knowledge is sought from; specific tangible (physical) sources of knowledge preferred; and the preferred sites for knowledge (venues).   Purpose  The purpose of this study was to explore the knowledge seeking patterns of care aides who provide care to residents in residential care facilities. I derived the data from semi-structured interviews with care aides. The primary research question was: What are the knowledge seeking patterns of care aides who are employed in residential care facilities? Secondary research questions were:  Why do care aides seek information?  How often do care aides seek information?   Where do care aides go in residential care facilities when they are seeking information (their preferred person or location)?   When are care aides most likely to gather information?  What types of tangible knowledge sources do care aides prefer? Significance A thorough examination of the knowledge seeking patterns of care aides is significant to both theoretical and practical discussions of residential care facility operation and care aide roles within that framework. Power structures, interpersonal relationships, individual values and personal motivations may all influence the knowledge seeking patterns of an individual care aide or group. This study enriches theoretical discussions about the culture and identity of care aides in residential care facilities and about how knowledge seeking is integrated into care aides’ perceptions of their job role and position within the health care team. Without a clear understanding of the knowledge seeking patterns of care aides, the methods selected by employers, supervisors, and policy makers for disseminating knowledge 5  may not be as effective as it could be. Thus, important information and details about care requirements, safety precautions, family directives or resident preferences may be lost. In order to promote the best possible care for residents, it is imperative that all health care workers operate together in a cohesive and collaborative manner. Clear and effective knowledge sharing is a necessary part of this cooperative practice. This study contributes new knowledge that may assist in the development of tools and strategies that align with the knowledge seeking patterns of care aides and may benefit them as well as those who supervise their work. By tailoring knowledge sources to the knowledge seeking patterns of the care aides, care plan directives could be communicated with maximum impact to achieve the highest standard of care for residents. Laschinger (2008) states that access to information contributes to workplace satisfaction, which in turn results in higher quality of care. Workplace satisfaction is also known to increase general resident satisfaction with their care and living situation (Liu, 2007) and to reduce staff turnover, which also contributes to improved quality of care (Castle & Engberg, 2005).  In addition, care aide program instructors could apply the findings of this study to their curricula, thereby improving teaching effectiveness, which can ultimate contribute to the development of a more knowledgeable, prepared and engaged workforce. Nursing supervisors may be able to use the findings to adapt bedside care documents, reporting tools and team knowledge sharing structures. Integrating the knowledge seeking patterns of care aides into the routine practices in nursing units could improve their teamwork, morale and productivity, resulting in better resident outcomes. In addition, based on the findings of this study, health care policy makers may be able to adapt staffing orientation programs, mentorships and continuing education initiatives to enhance care aide knowledge seeking.    6  CHAPTER 2: LITERATURE REVIEW In this chapter I review the relevant literature related to knowledge seeking patterns by care aides. I outline my search strategy and key findings from the body of work available. The following literature review is focused on what is generally known about care aide preferences for knowledge sources and their patterns of knowledge utilization. Also included is a summary of what is known about the knowledge sources and knowledge utilization of nurses, as a comparison population.  Search Strategy This literature search was conducted through two comprehensive databases: the Cumulative Index for Nursing and Allied Health Literature (CINAHL) (2006-2016) and the Education Resources Information Centre (ERIC) (2006-2016).  These databases were chosen because they are known to house an abundance of nursing, health and education literature. CINAHL is the most frequently accessed data base for research literature that is used by nurses and nursing managers, administrators and educators. The search was limited to peer-reviewed English language articles with abstracts and full text online.  The search terms and phrases are detailed in Table 1.  Table 1 Search Strategy Search Terms Primary terms searched in all possible parings with secondary terms Primary Terms                                                                                 Secondary Terms Care Aide                             Healthcare Assistant                             Communication Care Assistant                      Nurs* Aide                                            Decision Care Attendant                     Nurs* Assistant                                     Information Care Worker                        Support Worker                                     Knowledge Healthcare Aide                                                                                  Literacy 7  The use of the Boolean phrase “or” within each column, and the Boolean phrase “and” between the two columns resulted in a low number of articles, therefore the following search terms were also entered individually to ensure inclusion of all relevant articles: Unlicensed Assistive Personnel, Unlicensed Care*, Unregulated Care*, Unregulated Healthcare, Unlicensed Healthcare and Patient Support Assistant. The search was also extended to the University of British Columbia’s digital repository of online research and teaching materials, including theses and dissertations (cIRcle). One major paper from cIRcle and 2708 journal articles were identified initially. After duplicate articles were removed, and abstracts reviewed, 36 articles were retained for full review.  After reference lists of all retained articles were examined, one additional study published in 2005 was included due to its clear relevance to the research topic. Full results of the search are presented in Appendix A.   What is Known About Care Aide Preferences for Knowledge Sources  Multiple authors have explored the sources of knowledge preferred by care aides, and have found that certain types of knowledge are valued more than others. Knowledge sources can be broadly grouped into the two categories: “informal” and “formal”. Informal sources include verbal conversations, personal experiences, and information gathered about a resident through relationship building (Caspar, 2014; Furåker & Nillson, 2009; Janes, Sidani, Cott, & Rappolt, 2012; Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015; McClement, Wowchuk & Klaasen, 2009; Rasin & Kautz, 2007).  Formal sources include those sources gained through academic education, training programs, documented care directives, and workplace policies.  A Preference for Informal Knowledge Sources Most researchers suggest that care aides prefer informal rather than formal knowledge sources (Caspar, 2014; Furåker & Nillson, 2009; Estabrooks et al., 2015; Janes, Sidani, Cott, & Rappolt, 2012; Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015; Rasin & Kautz, 8  2007). Team sharing (which includes both observation of colleagues’ caregiving practices and discussions within the healthcare team), professional and personal life experiences, and observation of residents (including their behaviours, emotional status, and reactions to the caregiving) are examples of preferred informal knowledge sources. Kolanowski and colleagues (2015) found that care aides consider word-of-mouth as the most reliable knowledge source for resident care information in a residential care facility setting.  Direct care aide peer-to-peer oral report was the most common vehicle for this type of information sharing (Caspar, 2014; Kolanowski et al., 2015).  Some care aides explicitly stated that they preferred not to access formal documents such as care plans as a source of information because the care plans or other unit documentation about the residents were often developed without their participation and therefore did not accurately reflect their perceptions of the needs or preferences of their residents (Kolanowski et al., 2015). Rasin & Kautz (2007) found that care aides did incorporate formal care plans into decision-making if, and only if, they believed that the formal care plans provided current and accurate person-centred information about residents. Care plans were often not used because they were not updated, and were not updated because they were not used (Caspar, 2014). When care aides perceived that official policy or care directives were at odds with residents’ known preferences they were more likely to make decisions based on their personal experiences, moral values, and observations of the residents in the moment (Kontos, Miller, Mitchell, & Cott, 2010). Furåker & Nillson (2009) noted that some care aides reported little interest in acquiring formal knowledge about dementia, and instead chose to make care decisions based heavily on their prior personal and experiential knowledge of residents, and of dementia. Research has also shown that care aides consider it important to “know” their residents (Caspar, 2014; Rasin & Kautz, 2007; Mantzorou & Mastrogiannis, 2011; Tingström, Milberg, & Sund-Levander, 2010). 9  “To know” meant both understanding the individual resident’s patterns of response to situations and treatments, and knowing the individual personally (Mantzorou & Mastrogiannis, 2011). Cumulative personal experiences in dementia care in general and learning about individual resident’s patterns and preferences were noted as attributes of this “knowing” (Rasin & Kautz, 2007).  Care aides have indicated that knowing the residents “like the back of (their) hand(s)” was an important part of relationship building (Rasin & Kautz, 2007, p. 34).  The job was easier and safer, they said, if they were able to anticipate potential behavioural responses (Rasin & Kautz, 2007).  Finally, some care aides who reported knowing the residents well were able to distinguish early non-specific signs of illness by observing changes in the residents’ usual conditions or behaviours (Tingström et al., 2010). When deciding to administer pro re nata (PRN) medications, care aides who administered medications to residents relied heavily on resident-specific knowledge (Carder, 2011).  What is Known About Care Aide Patterns of Knowledge Utilization A number of authors have explored how care aides use knowledge in practice. These authors have focussed on theoretical, informal and formal knowledge utilization, as well as organizational efforts designed to enhance formal knowledge utilization and the influence of workplace culture on knowledge seeking and utilization.  Theoretical Knowledge Utilization  Only one theoretical article was found in relation to care aides and their utilization of knowledge. The theory of Figuring it Out in the Moment (Janes et al., 2012) provides some clarity as to how care aides might use knowledge to deliver care to residents. The theory of Figuring it Out in the Moment is rooted in the context of caring for clients with dementia but does not illuminate care aide knowledge seeking patterns.  According to Janes and associates (2012), knowledge utilization by care aides occurs in four interconnected phases of decision 10  making and action. The first phase, “Melding”, involves acquisition of knowledge by care aides. Possible choices for use of the knowledge are recognized, which will then be evaluated during the phase called “Contextualizing”. During the contextualizing phase, care aides create meaning by examining the knowledge and choices within a specific situation, considering particular details of the circumstances, and assessing their motivations, experiences and other intrinsic factors. The third phase is called “Trialing” which means to practice the knowledge by providing care to residents.  In the final phase, “Appraising”, care aides determine whether the knowledge utilization was effective by asking oneself if he or she did a “good job” (p. 16).  Informal Knowledge Utilization In addition to a preference for informal knowledge sources, care aides have been reported to make use of knowledge informally to make decisions about care delivery, break rules, or confirm their decisions (Carder, 2011; Kontos et al., 2010). In their observations of care aides in an assisted living setting Carder (2011) noted that care aide interpretations of resident symptoms or behaviours were a primary influence on decision making about whether or not a medication should be given. Observations of how each resident responded to a medication, in combination with an understanding of the resident needs and wishes, were developed over time (Carder, 2011).  According to Kontos and colleagues (2010), although care aides understood local mandates and institutional policies, they often engaged in rule breaking in order to provide care that they felt was in the best interest of residents. In this study care aides explained how they weighed the value of information gained through various knowledge sources in order to make decisions about resident care. These same authors also found that nursing supervisors believed that care aides used an internal auditing system to judge information and make choices rather than routinely utilizing resident care plans or other formal documentation sources within the unit 11  to make care decisions. Some care aides reported feeling “terrible” when they were required to follow procedures contrary to residents’ wishes and often chose to act in alignment with their own values and views of the situations presented (Kontos et al., 2010, p. 123).  Formal Knowledge Utilization Evidence-based practices. It is known that use of research findings in practice is linked to workplace context, including time pressures, and the direct relevance of the data to the specific care situation (Boström, Kajermo, Nordström, & Wallin, 2008; Estabrooks et al., 2005). Estabrooks and colleagues (2005) found that nurses were unlikely to review research that applied to their practice in a broad sense but would seek information that could be directly and immediately applied to a current medical problem. Even so, there was some evidence that care aides may be more likely to use research findings than professional nurses. Boström and associates (2008) examined hospital-based RNs caring for elderly patients and found that they were unlikely to use empirical evidence in their daily practice despite having a positive attitude towards research in general. In addition to time constraints, the nurses indicated that a lack of workplace culture that supports accessing empirical evidence, as well as unfamiliarity with the library systems, were barriers to using evidence-based practice when caring for geriatric clients. The same authors also found that higher levels of education positively influenced whether or not a nurse would access empirical evidence within the practice setting; nurses with baccalaureate degrees accessed research findings most often (Boström et al., 2008). Although this finding suggests that care aides may, with their shorter training programs, be unlikely to use research findings in comparison to other health professionals, Sales and colleagues (2015) discovered that care aides rated empirical evidence as more useful for improving quality indicators such as falls, pressure ulcers, and behaviours than care managers, nurses or any other allied health workers.  12  Care plans. Care plans, whether in the residents’ legal charts or as bed-side care directives, have the potential to provide care aides with much of the knowledge required to provide safe and personalized care for an individual resident. As with other formal knowledge sources, however, care plans were not identified in the literature as a preferred option. A recurrent theme was exclusion of care aides from the care planning process (Caspar, 2014; Kolanowski et al., 2015; Kontos, Miller, & Mitchell, 2009; Rasin & Kautz, 2007). Care aides were often excluded from care planning when technological systems, such as the computer-based Resident Assessment Instrument - Minimum Data Set (RAI-MDS), were implemented (Kontos, Miller, & Mitchell, 2009). Despite supervisor expectations that all team members would be included during care plan development and updating, limited computer access, low status within a hierarchy of health professionals, time constraints and poor team collaboration meant that care aides were sometimes not consulted at all (Kontos et al., 2009). As a result, the care aides in this study felt that the care plans created through technological systems lacked important information about resident behaviours and preferences gained through everyday interactions and complex interpersonal relationships with residents (Kontos et al., 2009). Efforts designed to enhance formal knowledge utilization. Despite evidence that most care aides prefer informal sources of knowledge, many researchers have tested training programs designed to encourage care aides to access and use formal sources of knowledge (Denham, Meyer, Rathbun, Toborg, & Thornton, 2006; Hobday, Savik, Smith, & Gaugler, 2010; Irvine et al., 2013; Kemeny, Boettcher, DeShon, & Stevens, 2006; Kpodo, C., Kemp, A., Adams, L. & Burden, B., 2015; Lerner, Resnick, Galik, & Russ, K. G., 2010; Resnick, Cayo, Galik, & Pretzer-Aboff, 2009; Wilson et al., 2011). In residential care facilities, this training may include educational methods such as computer-based learning modules (Denham et al., 2006; Hobday et al., 2010; Irvine et al., 2013), virtual simulation role playing (Kemeny et al., 2006; Wilson et al., 13  2011), advanced training courses (Lerner et al., 2010; Resnick et al., 2009), and interactive classroom settings (Kemeny et al., 2006; Wilson, et al., 2011). A significant number of researchers reported that care aides were not consistently well-informed about evidence-based knowledge seeking or knowledge utilization practices in residential care facilities, regardless of the knowledge sources in place (Demarré et al., 2011; Mody, Sanjay, Galecki, Chen, & Krein, 2010; Whittaker, Kernohan, Hasson, Howard & McLaughlin, 2007).  Selection and Evaluation of Knowledge Taylor, Sims, and Haines (2014) found that when care aides used formal knowledge sources for decision making, they often combined them with informal knowledge.  For example, when assisting a resident with mobility needs, some care aides combined formal knowledge sources such as care plans and transfer assessments with informal knowledge sources such as conversations with residents or co-workers (including physiotherapists and mobility specialists), and their personal intuitions or habits (experiential knowledge) (Taylor et al., 2014). The care aide participants in this study reported using their observations of resident behaviours to determine whether or not the formal care plans were appropriate at that point in time. If the care plans were deemed inappropriate at that time, informal knowledge sources were used instead (Taylor et al., 2014). Ethical considerations also influenced care aide use of both formal and informal knowledge. In their analysis of care aides’ experiences with lying to residents who were living with dementia, Tuckett (2012) found that care aides created an internal ethical framework in order to support their decision making. If re-orientating the resident to reality was expected to create more harm than good at that time, care aides could resolve their inner conflict about telling a lie. The assessment of the ethical dilemma was based both on care aides’ knowledge of accepted dementia care practices as well as their assessment of a particular resident’s level of understanding and reality orientation.  14  The Influence of Workplace Culture on Knowledge Seeking and Utilization Workplace culture, specifically the concept of knowledge as power, influenced the knowledge seeking and utilization practices of care aides. Commonly in residential care facilities, the nurse manager or nurse in charge had the greatest access to knowledge about residents, followed by unit nurses, and then care aides (Kontos et al., 2009). Multiple authors have linked care aide access to information with their perception of power for decision making about resident care (Caspar, 2014; Caspar & O’Rourke, 2008; Chaudhuri, Yeatts & Cready, 2013; Kolanowski et al., 2015; Kontos et al., 2009; Rasin & Kautz, 2007) When a sense of empowerment was achieved, care aides were more likely to use the knowledge they had gathered about their residents to make autonomous decisions, which the care aides stated allowed them more flexibility to provide individualized, and more effective, care. (Caspar & O’Rourke, 2008; Chaudhuri, Yeatts & Cready, 2013) Knowledge Sources and Knowledge Utilization of Professional Nurses Professional nurses, consistent with care aides, are also known to favor informal knowledge sources (Estabrooks et al., 2005). According to Estabrooks and associates (2005) nurses’ self-reported knowledge sources fell into four broad groupings: social interactions, experiential knowledge, documentary sources, and a priori knowledge. Of these four, informal social interactions and forms of communication dominated, in particular, speaking with other nurses, health professionals, patients and their families. The preference for informal knowledge sources was also reported in multiple other studies (Bringsvora, Bentsenb, & Berland, 2014; Kemeny et al., 2006; Mills, Field & Cant, 2009; Yadav & Fealy, 2012). Informal knowledge sources, such as social interactions and experiences, allowed nurses not only to gain information, but also to receive “affirmational support” from peers (Estabrooks et al., 2005, p. 464). Affirmational support allowed nurses to cope with the natural uncertainties within their practices 15  as they actively worked to problem solve and collaborate (Estabrooks et al., 2005).  It was unclear whether the concept of “affirmational support” is also a factor in care aides’ preference for informal knowledge. When conflict occurred between formal and experiential sources, researchers found that nurses were more likely to choose knowledge gained from their own personal experience (Estabrooks et al., 2005), echoing the choices made by care aides when rule breaking (Kontos et al., 2010) or affirming decisions (Taylor et al., 2014). This was particularly true when formal sources of knowledge suggested a change in established practices (Sales et al., 2015). Concluding Remarks Acquisition and usage (or utilization) of knowledge were influenced by a number of factors apart from the specific knowledge sources, including career goals, empowerment, ethical considerations and time. Blau, Chapman and Neri (2015) found that care aides who viewed their work as a stepping stone to another career or job role, were more likely to focus on gaining skills rather than learning job-specific knowledge that may improve the quality of their overall caregiving. On the other hand, when care aides had access to information, they were more likely to provide individualized care to residents (Caspar & O’Rourke, 2008). Finally, researchers concluded that both care aides and professional nurses reported time constraints as a significant factor influencing knowledge seeking (Caspar & O’Rourke, 2008; Kontos et al., 2009). Knopp-Sihota, Niehaus, Squires, Norton, & Estabrooks (2015) found that 86% of care aides felt rushed to complete their work, and 75% reported that they had left at least one care task uncompleted during their last shift.   In summary, the evidence suggests that care aides prefer, and are more likely to use, informal knowledge sources over formal ones. In particular, verbal communication, personal experience, and knowledge gained by developing a relationship with the resident were found to 16  be the most frequently sought-after and used sources. The current evidence, however, is general in nature and does not specify or examine the holistic concept of knowledge seeking patterns. In order for employers, educators and policy makers to develop effective knowledge sharing practices to impact care quality for residents, a deeper understanding of care aide knowledge seeking patterns is required.   17  CHAPTER 3: METHOD The aim of this chapter is to provide the reader with a clear understanding of the research processes I employed to explore the knowledge seeking patterns of care aides. The method of exploration was semi-structured interviews with care aides. My primary goal was to produce a rich, meaningful account of the knowledge seeking patterns of care aides, as they described them, and to gather strong evidence from which to form my conclusions. I begin this chapter with a reflection on my professional experiences that underpinned my research approach. Then I discuss the setting for the study and the strategies I used to recruit participants, collect data, and analyze data in order to answer my research questions. Finally, I describe how rigour was incorporated into this study.  Reflexivity  In collaboration with my participants, I generated data and to some extent, my interpretation and analysis reflects who I am as a person, a professional and a scholar. Therefore, it is important to articulate my assumptions and the conceptual lens guiding my work (Cohen & Crabtree, 2008).  I am a registered nurse and I live, work and study in the community in which I conducted this research. The focus of my graduate program has been gerontology and education, with a particular interest in elder care and residential care facility settings. During my undergraduate nursing program, I worked for three years as a personal care aide for private clients, and those in a shared-caregiver system, in their own homes. Since 2008, I have been employed as a staff nurse in both privately and publicly funded residential care facilities. My regular duties have included collaboration with care aides, supervising care aides, and providing care to residents. I have also been employed as a manager in a 34-bed privately funded residential care facility and as a clinical practice educator with a caseload of 550 privately and publicly funded care beds.  18  I have developed and presented curriculum to care aides and registered nurses on a wide-range of health and practice related topics. A major project that I completed in this role was the compilation and presentation of a regional orientation program for care aides, detailing their roles, responsibilities and performance expectations, including resources and skill validation tools. I have also worked as an instructor for care aide and practical nursing students. In a private college, I taught gerontology and clinical skills to care aides in a classroom setting. I have taught and supervised first year practical nurses during their residential care facility clinical placements and acted as an independent competency evaluator for care aides intending to return to practice after an extended absence.  I have been employed in the public health sector as a Licensing Officer, operating within provincial legislation, the British Columbia Residential Care Regulation and Community and Assisted Living Act, to complete inspections in public and private residential care facilities and group home style elder care facilities. Currently I am employed in a provincially funded 64-bed complex care residential care facility, as the Residential Care Coordinator.  I am responsible for overseeing all care aides and nurses, as well as managing and coordinating the care provided by allied health professionals. In my current role, I audit care aide performance and provide coaching and education in accordance with established job descriptions and competencies.    As a researcher, the benefits of my experiences in residential care facilities were my understanding of the goals, practice norms, reporting structures and challenges of working in these environments. I believe that my experiences helped me to quickly develop rapport with the participants, and to recognize discrepancies between their narratives and common practice which warranted deeper exploration. Conversely, I learned that to become a qualitative researcher requires a whole new way of thinking about what counts as evidence. While I was familiar with the aim of quantitative methods to collect objective evidence, I came to understand that the 19  findings from my qualitative study would be inextricably connected to my subjective point-of-view. As a qualitative researcher, I was the person (the instrument) who generated and interpreted the data; therefore, the quality of my data and the quality of my interpretations were contingent on my efforts. During data collection, I reminded myself that my previous perspectives and biases as a nurse educator, quality review team member, licensing officer, and residential care coordinator, could potentially influence the type of data that I generated. When I interviewed the care aides, I understood that the quality of my data would be dependent on my ability to attend to the flow of conversations and I concentrated on using interviewing skills such as probes, silence, and follow-up questions that I learned from previous roles in my career.  I was determined to make every effort to effectively collect rich data and in conjunction with my supervisor, to develop a nuanced and complete interpretation congruent with the philosophical underpinnings of the research.  When analyzing the data, I employed a continuous process of verifying themes with my supervisor, to minimize the risk of bias based on my personal and professional experiences. Setting In my current role as a Residential Care Coordinator in a publicly owned residential care facility, I am in a position of authority in relation to any care aide working in a residential care facility owned by my employer. Therefore, this study was conducted in three privately owned, faith-based, residential care facilities in an urban area of British Columbia with which I held no professional affiliation. The homes provided services to 96, 100, and 138 residents and included both privately and publicly funded beds. While persons living with dementia resided in all of the units within the residential care facilities, there were also designated dementia and special care units within the buildings.  I decided to access multiple settings as an attempt to account for the possibility of idiosyncratic differences between institutional cultures in the individual facilities. 20  All three study homes were monitored for legal standards of quality and safety by the local licensing office, in accordance with provincial law.  Participant Sample Inclusion / Exclusion Criteria I focused on recruiting care aides who worked full-time, part-time, or casually for six months or longer at one or more of the three participating facilities. I did not deliberately exclude any care aides if they wished to participate unless they had previously worked directly with me, or under my supervision, in any employment or academic setting. The aim of my study was to gather many different emic viewpoints and descriptions of care aides so nursing students, registered nurses, licensed practical nurses, managers, residents and their family members were also excluded as participants. Ultimately, everyone who participated in the study met the inclusion criteria.  Sample Size The number of participants recruited for this study was determined by analytic saturation.  Analytic saturation is the point at which continuing data collection and analysis becomes redundant (Corbin & Strauss, 2008) and I stopped interviewing when no new information was emerging during the interviews. Based on the average sample sizes of similar studies (Table 2), I had anticipated that my sample size would be 10-12 participants.  While I was unable to locate any qualitative studies where researchers applied Thematic Analysis to semi-structured interviews specifically with care aides, I did find studies where researchers applied Thematic Analysis to semi-structured interviews with health care professionals, patients, and family members. My final sample size of eight participants was consistent with the sample sizes in these studies.   21  Table 2 Average Sample Sizes of Similar Qualitative Studies Authors Date Purpose Method Population Participants Baby, Glue & Carlyle 2014 To explore and describe mental health nurses’ experiences of patient assaults Thematic Analysis of semi-structured interviews Nurses 14 Blattner,  Nixon, Jaye & Dovey 2010 To identify the perceived impact of point-of-care testing on clinicians and the community Thematic Analysis of semi-structured interviews Physicians, nurses and other health care professionals 13 Douglas, Hamilton & Grubs 2009 To explore the effect of BRCA gene testing on family relationships Thematic Analysis of open-ended interviews, secondary analysis Patients and families 12 Galvin,  Suominen, Morgan,  O’Connell & Smith 2015 To explore the stress in UK mental health nursing students Thematic Analysis of semi-structured interviews Nursing Students 12 Jenkins & Huntington 2016 To explore the experiences of internationally qualified nurses who transitioned to New Zealand as RNs in aged care Thematic Analysis of in-depth interviews and focus group Nurses 6 Molin, Egerod, Staun, Valentiner, Lange & Langberg 2016 To explore General Practitioners’ perceptions of COPD treatment and patient management of COPD Thematic Analysis of semi-structured interviews Physicians 8 Stanners, Barton, Shakib & Winefield 2014 To explore experiences of depression diagnosis and treatment amongst multimorbid patients referred to a metropolitan multidisciplinary outpatient clinic Thematic Analysis of semi-structured interviews Patients 12 (saturation noted after 10 interviews)  22  Authors Date Purpose Method Population Participants Stanyon, Griffiths, Thomas &  Gordon 2016 To describe the views of healthcare workers on the facilitators of communication with people with dementia in a care setting Thematic Analysis of semi-structured interviews Care aides, nurses, allied health therapists and physicians 16 Strachan, Yellowlees & Quigley 2015 To explore General Practitioner’s assessment and treatment of older patients, and their expectations and experience of referral to secondary care Thematic Analysis of group interviews (2-5 participants per group) Physicians 9 Total # of Studies = 8 Average Sample Size = 10.75  Recruitment Process I used convenience sampling to recruit eight care aides who were currently working in one or more of the three residential care facilities. The sample was self-selected and participation was voluntary. I began the recruitment process by meeting with the Director of Operations to describe the study and obtain a letter of support. To protect confidentiality of the participants, I have not included the letter here, but it was submitted with my proposal to the University of British Columbia Behavioural Research Ethics Board (UBC-BREB). The privately-owned study homes did not have an independent ethics review board, but because some of the beds in the homes were publicly funded, I requested a harmonized review with the Interior Health Authority. Once harmonized ethical approval was obtained, I met with the managers at all three study sites to make arrangements for recruitment. I recruited both in person and via poster.  In person recruitment. I hosted two information sessions at each residential care facility. During these sessions, I introduced the study and explained the general nature and purpose, the consent process, the confidential nature of the interviews, the honorarium, and the time commitment required. I invited any interested care aides to contact me if they needed more 23  information or if they wished to participate in the study. I passed out the recruitment handout (Appendix B), which contained a brief summary of the research purpose and design, risks, benefits, eligibility criteria, my contact information and my supervisor’s contact information. I also answered any immediate questions from the staff. All potential participants were advised that participation in the study was voluntary, and that no information would be divulged to anyone other than to my supervisor.  It was up to each individual participant to contact me. After an individual indicated that she was willing to participate, and I confirmed that she was eligible, an interview was scheduled at least 24 hours in advance, at a mutually convenient time. Three participants contacted me about an interview after meeting me once (during recruitment). Four participants waited to contact me until after they had seen me on two separate occasions at their worksites (during the recruitment and data collection processes). Poster recruitment. I hung ten colour posters (Appendix C) in public locations within each study home. A single participant contacted me in response to the poster alone, without having met me during recruitment at the worksites. Participant Characteristics  I collected data about the characteristics of the participants for two reasons: 1) to show similarities or differences between the participants, and 2) so that readers can make an informed choice if they wish to transfer the results of my study to the context they are interested in. Transferability is the extent to which the research findings may be transferred to other settings or groups, as opposed to generalizability, the extent to which the research findings may be generalized across the population (Polit and Hungler, 1995). It was not my intention to generalize the findings of this study to all care aides. The readers must be able to evaluate the similarities between this study and their own situations to determine if transferability is warranted. I created a data collection questionnaire to gather this information from the participants (Appendix D). Care 24  aide characteristics were collected prior to each interview, were considered to be part of the data, and were stored in the same locked filing cabinet as the memos, field notes, and transcripts. To protect the identity of the participants during dissemination of the study results, some of the data has been removed. Key participant characteristics are presented in Table 3. All of the participants in this study self-identified as female.  Table 3 Participant Characteristics Characteristic Numeric Age Range  Under 30 30-40  Over 40  Average       22-47  2 2 4  35.75 Gender Self-Identified Female  8 Years of Experience Range  Under 3 3-6 7-10 Over 10  Average  1.5-10  3 1 2 2  5.6 Employment Status Regular Full-time/Part-time Casual  5 3 Years with Current Employer Range  Under 3 3-6 7-10 Over 10  Average  1.5-10  4 1 2 1  4.7 25  Characteristic Numeric Years on Current Unit Range  Under 3 3-6 7-10 Over 10  Average  0.75-10  4 3 0 1  3.25 Same Employer Since Start of Work as a Care Aide                                                  Total  7 Type of Care Provided on Current Unit Complex Care Dementia/Behavioural Care All (Casual/Float Staff)  2 3 3 Residents per Care Aide on Current Unit/Shift Average  8.3 Highest Level of Formal Education High school Graduate Some College/University  Degree  4 3 1 Length of Formal Care Aide Training Up to 6 months More than 6 months  1 7 Country of Origin Canada Other  5 3 First Language English Other  6 2 English Verbal Level (self-reported) Fluent (or English as First Language)  8 English Reading Level (self-reported) Very Good Good  6 2  Data Collection Data were collected in the form of audio-recorded semi-structured interviews with consenting care aide participants over a period of two months in 2017. Written consent 26  (Appendix E) and key participant characteristics (Appendix D) were collected prior to the start of each interview.  Each of these aspects is outlined in further detail below.  Potential Risks The goal of this study was to gain an in-depth understanding of care aide knowledge seeking patterns. As a researcher, I was obliged to anticipate possible outcomes of the research and to weigh possible benefits and harms. I anticipated that there were three potential harms. First, the research process could provoke a feeling of apprehension for potential participants. Second, the participants might fear that their responses would be leaked to their managers. Third, potential participants might feel pressure to participate due to pre-existing power-over relationships.   Procedures for protecting against or minimizing any potential risks. Participants who chose to take part in this study were at risk of experiencing an imbalance of power, or feelings of vulnerability and emotional discomfort. The nature of the participant-researcher relationship, and my position in the local health care community contributed to an imbalance of power. To mitigate this risk, I invited participants to ask questions before and after the interviews and provided them with my contact information. I gave them assurances that I would be receptive to their contacting me if they had any further questions or concerns. If, at any time during the interview, a care aide expressed distress or appeared to be experiencing distress I was prepared to stop the interview.  Signs of distress that I looked for included, but were not limited to, tears, grimacing or pained facial expressions, significant change in tone, volume or quality of voice, and repeated hesitancy to respond to questions.  To minimize apprehension, I explained to the participants how confidentiality and privacy would be maintained during the research process and how the findings would be disseminated and used.  I advised the participants that I would: 27  1. Maintain their confidentiality by using assigned pseudonyms. 2. Remove all identifying data including names, places, facilities, etc. and replace them with a descriptor (for example, manager, name of facility, friend, co-worker).  The agency was given the pseudonym “Elder Enterprises” and the three residential care facilities were kept confidential by removing the names and using generic terms such as “facility” or “workplace”. 3. Keep all field notes and memos in a locked filing cabinet in my supervisor’s secured office on the university campus.  4. Keep the consent forms and the master list linking the pseudonyms to the participants in a locked filing cabinet separate from the transcripts and notes and digitally recorded files (in my supervisor’s locked office on the university campus).  5. Remove any identifying information from quotes including names of agencies prior to dissemination of findings. 6. Aggregate the participant characteristics and demographics prior to dissemination of findings so that individual participants were unidentifiable by this data. 7. Remove or replace a word or phrase if I thought that the word or phrase might pose a risk to exposing a participant’s identity. 8. Advise participants that they did not have to answer a question if they did not want to, that they could withdraw from the study at any point without penalty and that they could request that audio-recording be stopped at any time. 9. Not discuss contents of specific interviews, preliminary analyses or findings with anyone other than my supervisor. When discussion of my emerging findings was required for my committee, only aggregate and depersonalized data would be used.   28  10. Reiterate to participants that my role was to maintain neutrality while giving voice to them and that my findings would be just one interpretation of the experience of being a care aide. 11. Use a transcriptionist who had signed a privacy/confidentiality policy (Appendix F). In order to accommodate a wide range of interactive styles, varied personalities, and mixed needs, I used six strategies designed to reduce power differentials and help the participants feel as safe and as comfortable as possible during interviews, in order to obtain optimal experiential data:   1. I did not interview any care aides who had previously worked directly with me, or under my supervision, in any employment or academic setting. 2. The interviews occurred in private locations that were safe and convenient for me, safe and convenient for the participants, comfortable, neutral and quiet. For fullest understanding, I collected data in the participants’ natural work environment when agreeable to them because qualitative research is based on a naturalistic paradigm, or the belief that realities cannot be understood in isolation from their contexts (Keele, 2011).  Interviews that occurred in the work environment took place in a meeting room within the residential care facility.  I placed a “Do Not Disturb” sign on the outside of the door during the interviews and closed the door and window blinds. These participants were informed that there was a slight risk that someone would know that they were participating in the study, but that person would not know what they actually said.  If a participant did not feel comfortable being interviewed at the workplace I arranged to meet them in a coffee shop or other location that was quiet and private enough for audio-recording. Three interviews were conducted in the workplace and five interviews were conducted in local coffee shops or outdoor spaces.  29  3. Buddy support:  Potential participants might feel afraid to face a researcher alone and might be more willing to participate if they are allowed a buddy (another care aide) for support.  During recruitment, therefore, potential participants were advised that they could be interviewed together if they so desired.  This strategy was aimed at increasing participant comfort by reducing feelings of pressure and scrutiny. No participants chose the dyad option. 4. Follow-up:  Although all participants were offered the opportunity to follow-up in person, by telephone, or by email in case they thought of something else they wish they had said, no participants contacted me after the interviews. 5. During any meetings or interviews with potential participants I wore casual clothing comprised of denim pants, a simple sweater or top, and running shoes. I did not wear expensive or elaborate jewelry, and I did not wear make-up.  6. Honorarium:  Each participant was offered a $20 Visa gift card as acknowledgement for her time and effort. The average wage for a care aide in BC is $16-$26.30 per hour (Province of British Columbia, 2017). The $20.00 Visa gift card was intended to be similar to 45-60 minutes of wages. Gift cards are based on the principle of reciprocity and an “act of respect, acknowledging the essential nature of (participant) contributions, their expertise, and their wisdom as critical component(s) of (the) research” (Morse, 2005, p. 727). As a researcher, I felt the need to reciprocate. In addition, childcare and or parking expenses incurred by participants were reimbursed up to a maximum of an additional $20.00. Information about the honorarium was included on the study poster and information sheet.    30  Consent Process I maintained confidentiality of participants through the use of pseudonyms. Each participant was asked to choose from a prearranged list of potential pseudonyms (Appendix G) or to select a pseudonym of their own. I made the participants aware that participation in the study was voluntary, and that no identifying information would be divulged to anyone, including managers or directors of care, other than my research supervisor. I advised that confidentiality could not be guaranteed when direct quotes were used during data analysis and dissemination of results, and that although I would put extensive and conscientious effort into suppressing any quotes that might result in identification of the participant some risk would always be present. Finally, I advised the participants that they did not have to answer a question if they did not want to, that they could withdraw from the study at any point, and that they could request that audio-recording be stopped at any time without consequence. Receipt of the Visa gift card was not contingent on complete participation in the study. I informed participants that if they decided to withdraw prior to transcription, the interview recording and any associated notes would to be destroyed. I stated that although I could not "wipe" the information out of my memory, I would not use anything that the participant said in the final thesis. If they decided to withdraw from the study after the interview had been transcribed and analyzed, the information would be included as part of the final thesis, however I would not use any of the quotes from that participant as examples. No participants withdrew from this study. The information sheets also contained a statement that a) the study was in partial fulfillment of the requirements for the degree of Master of Science in Nursing, and b) the thesis would be a public document that would be available on the internet via the cIRcle database.  With the participants’ permission, I audio-recorded the interviews. I also wrote memos during the interviews. Memos are key words, interesting thoughts, hypotheses, short sentences or 31  quotes discreetly written on a small notepad during an interview for the purpose of stimulating my memory later in the interview and post-interview (Speziale & Carpenter, 2003).  All of the participants consented to audio-recording. After each interview, I wrote field notes to document my activities, circumstances and thoughts. Field notes are unpolished, short but descriptive notes about the interview, the environment or the participant, and sometimes included my impressions and incidental observations (Speziale & Carpenter, 2003).  Memos and field notes were considered to be data; therefore, they have been stored securely in the same manner as other paper data. Interviews During the interviews, the conversations were focused on the knowledge seeking patterns of care aides. I referred to guiding questions (Appendix H) and used additional questions and prompts as needed. I assured the participants that there were no preferable responses as I stated “I would like to understand what you do to get the information that you need to give care to the residents. What you do will be different from what other people do.” The interviews varied in length from 30-61 minutes, according to the availability and verbosity of the participants. The average length of the interviews was 49 minutes. Data Management I transferred audio data from the recorder to my password protected laptop computer on the same day as it was recorded and then backed up the data immediately by copying the file to a removable password protected portable flash drive. The password protected portable flash drive was necessary to transfer the file to the transcriptionist’s password protected laptop. While I personally completed the transcription for the first five interviews, I required a transcriptionist to assist me to complete this project due to medical reasons. The transcriptionist signed a privacy/confidentiality policy (Appendix F) and met with me in person to transfer the transcripts 32  back onto the password protected portable flash drive. I then transferred these files onto my password protected laptop and the transcriptionist deleted the document and audio files from her laptop, which I witnessed. I then deleted all files from the portable flash drive. I checked the word documents for accuracy and removed any identifying information before it was loaded into NVivo qualitative software for data analysis. I kept all notes and memos in a secure locked filing cabinet in my supervisor’s locked office on the university campus. I stored the consent forms and the master list linking the pseudonyms to the participants in a locked filing cabinet separate from the transcripts and notes and digitally recorded files (in my supervisor’s locked office on the university campus). I will retain all data for five years post publication as per the Behavioural Research Ethics Board requirements.  Data Analysis and Interpretation  I used Thematic Analysis as described by Braun and Clarke (2006) to analyse my data. Thematic Analysis is a systematic process used to identify explicit and implicit ideas within a body of text (Namey, Guest, Thairu, & Johnson, 2008). Thematic Analysis is a highly usable, flexible and stand-alone method for qualitative research and offers “rich and compelling insights in to the real worlds, experiences and perspectives” of the participants (Braun & Clarke, 2014, p. 1). The Braun and Clarke method of Thematic Analysis has been employed by qualitative researchers to explore a wide variety of health care topics and populations, including residents of residential care facilities and residential care facility staff. Lopez, Mazor, Mitchell and Givens (2013) employed Braun and Clarke’s steps to analyze interviews with persons living with dementia in residential care facilities, while Van Hoof and colleagues (2016) used this method to explore residential care facility residents’ sense of home related to the presence of their personal possessions.  33  In Canada, Braun and Clarke’s method of Thematic Analysis has been used by researchers to explore nurse experiences of moral distress in residential care facilities (Edwards, McClement, & Read, 2013) and nurse experiences of distress when caring for persons with dementia (Spenceley, Witcher, Hagen, Hall & Kardolus-Wilson, 2015). In Norway, Dreyer, Førde and Novedt (2010) used Thematic Analysis to explore how physicians and nurses in residential care facilities justified decisions about life-prolonging treatments, while in Australia, Gao, Tilse, Wilson, Tuckett and Newcombe (2015) used this method to explore how residential care facility care aides and nurses perceive their jobs and intend to progress in their careers.   Thematic Analysis is a systematic process and is comprised of distinct phases. I followed the process through the six phases, as described by Braun and Clarke (2006). Each of these phases of analysis is described below:  Phase 1- Familiarizing Oneself with the Data The purpose of Phase 1 was to become familiar with the data by immersing myself in the material. Transcription of interviews and intentional reading and re-reading of the data with minor note taking are the activities that Braun and Clarke recommend. I began my process of immersion by listening to each of the audio files twice, without taking any notes. I then proceeded to transcribe five of the eight interviews verbatim. I listened to the audio files an additional three times or more to complete the transcript. For the remaining three files that were transcribed by the transcriptionist, I listened to each file an additional three time as well, while reading through the transcript and making any required edits. Next, I reread all of the transcripts as a group, and began to make minor notes about ideas and patterns that were beginning to take shape (Appendix I).   34  Phase 2- Generating Initial Codes During Phase 2, I prepared an initial framework of codes from the entire data set. I began by reviewing the data for initial sections of interest that could potentially provide “meaning” in relation to the research questions and assigning subject titles/codes to data excerpts. I worked through each transcript individually, using NVivo qualitative software to capture sections of text that represented a specific idea, or experience, that may have been of importance to the topic of knowledge seeking. The codes used at this time were loose descriptions of topics, with some codes being much more distinguished, or stronger, than other codes. As I worked through the transcripts, I added new codes at different times. At the end of this phase I reviewed each of the transcripts again against the coding structure to verify that the notations remained valid.  I noted initial relationships between some of the codes, but left the bulk of the coding as single-items during this phase. I identified 52 initial codes. Appendix J captures an overview of the initial code list and frequency of the codes at that time. Phase 3- Searching for Themes Phase 3 involved the creation of an initial set of themes. To complete this phase, Braun and Clarke recommend sorting coded data into theme groups, using tables or mind maps to organize ideas, and frequent checking against the original sources for clarity and accuracy. I followed each of these steps throughout my process. Themes can be understood as capturing “something important about the data in relation to the research question, and represent some level of patterned response or meaning within the data” (Braun & Clarke, 2006, p. 82). I reviewed the initial codes and began sorting them into potential themes.  At this time, some codes fit into more than one theme, and some appeared to be outliers, resulting in single-item themes. During this phase I attached descriptions to individual themes, but didn’t name any. I observed possible links to my primary and secondary questions and noted them for refinement in the next steps. At the 35  end of this phase I had a list of potential themes and the associated codes for further scrutiny (Appendix K). Phase 4- Reviewing Themes In the fourth phase, my goal was to refine the themes by grouping and regrouping the codes as needed to reach homogeneity and coherence of themes in relation to the data. At the end of this stage I aimed to refine my thematic map to clarify themes, subthemes and associated ideas. I looked at the initial themes and considered possible links between them. I combined similar themes and sub-themes to reduce the total number, and the remaining groupings were organized into major themes and subthemes. As Braun and Clarke had directed, I worked to sort the data to eliminate any outliers, and to find sets of themes that included all texts, without forcing any items to fit a given theme. To achieve this, I first reviewed all of the data extracts attached to each code to check for congruency. I made refinements to the codes at this time. Next, I re-read the entire data set again, to assess the accuracy of the themes as being representative of the data. During this process, I coded any additional data I had previously missed or incorrectly coded. At the end of Phase 4, I created a colour-coded visual map to provide clarity to my thematic framework (Appendix L). Phase 5- Defining and Naming Themes Phase 5 was the final stage of analysis and included a revision of themes, creation of theme titles, and a check for accuracy of themes with the original data. I re-read through all interview transcripts, with the list of themes on hand. I compared the themes in context with the original transcript data to make sure that I hadn’t inadvertently missed something. I then examined the themes both individually and in relation to one another, creating a clear definition for each theme, and finally named each theme. During this process, I did not find that I had any new questions about the data which would require further interviews. After completing Phase 5, I 36  felt clear that analytic saturation had been achieved and no further data collection was required. At the conclusion of this stage I created a final Thematic Map to illustrate the structure of the themes (Figure 1). Rigour Rigour ensures that the results are valid and closely represent the descriptions and experiences of the people studied (Richards & Morse, 2013). To maintain rigour I concentrated on what the participants said, being open-minded and responsive to their statements, and avoiding any preconceived assumptions. I proceeded with one method to analyze the data (the Braun and Clarke method of Thematic Analysis), and continued to recruit participants and collect data until I achieved analytic saturation. I created and kept field notes and memos regarding the interviews to provide an audit trail for the research, and to provide context which contributed to the consistency of the analysis. After completing my initial coding, I met with committee members to share my work and verify that my codes were valid. I met with my supervisor at later dates, to present my Thematic Map and share the progression of the themes through each of the remaining four phases of analysis. Together, we reviewed my steps through the phases of Thematic Analysis to ensure consistency in the coding and themes. I did not undertake member checking because the final themes were “abstracted” from multiple participants and most likely would not be recognizable to individual participants (Morse, Barrett, Mayan, Olson, & Spiers, 2002; Sandelowski, 1993).     37  CHAPTER 4: FINDINGS The purpose of this study was to explore the knowledge seeking patterns of care aides who provide care to residents in residential care facilities. I divided this chapter into five sections that reflect the five themes that emerged from my analysis: What I Read, What I Hear, What I Already Know, When I Have Time, and Why I Seek. Within each theme there are a number of subthemes. During our conversations, the participants identified a number of tangible and non-tangible knowledge sources that are described in the first two themes: What I Read and What I Hear. The participants’ ideas about knowledge that they have gleaned from life experiences, training, or other ways of knowing that do not require active knowledge seeking in the present moment are described in the third theme: What I Already Know. The fourth theme, When I Have Time contains details about the frequency and timing of knowledge seeking for the purpose of providing resident care. The final theme, Why I Seek, illuminates care aide motivations for knowledge seeking from personal and job-based perspectives. Thick, rich descriptions in the form of participant quotes accompany each theme.  I begin this chapter with a summary of the themes and brief descriptions (Table 4), a thematic map which illustrates the relationships between the final themes and subthemes (Figure 1), and a glossary of industry-specific words and slang used by the participants during the interviews (Table 5). The five themes are presented in detail following the illustrative tables and figure.    38  Table 4 Summary of Themes Theme Description What I Read Knowledge seeking through tangible sources such as digital and hard copy documentation  What I Hear Knowledge seeking through verbal conversations with teammates, residents and family members What I Already Know Knowledge that is gained through alternative ways of knowing; active knowledge seeking is not necessary When I Have Time The availability of time for knowledge seeking and the specific timing when knowledge seeking occurs Why I Seek Participant motivations for engaging in knowledge seeking    Figure 1.   Thematic Map  39  Table 5 Glossary Word or Term Meaning 24-hour book, 24-hour report A team reporting tool providing a summary of events and changes that have occurred on a given unit within the previous 24 hours 911 Emergency situation, may actually require calling the emergency dispatch line “911” Activities Activities workers/aides, staff members trained in recreational and leisure therapy. May include recreation therapists ADL sheet Activities of Daily Living sheet, a care plan document located at the bedside or within the resident’s room Broda® chair A wheelchair specialized for use with older adults. Often includes features such as additional trunk/limb support and tilt/recline functions Care plans Digital or paper documents containing details about the care needs of a resident. May be used as a single or collective term, grouping care plan documents with ADL sheets, or other documents Ceiling lift A mechanical lifting device mounted to a ceiling, used for transferring residents in/out of bed, on/off toilet, in/out of wheelchair etc. Dementia unit A unit within the facility designated for the care of clients with behavioural challenges related to dementia, frequently a locked unit Derma-sleeves A protective garment worn over arms or legs to prevent minor tissue trauma from bumping or scratching limbs, often made of memory foam General (fluid) Regular texture fluid, not thickened (thin fluid) Google™ A popular internet search engine, may be used as a noun or verb Hip-protectors A garment worn to protect the hips from fracture, commonly designed as padded pants or underpants HS care Personal care completed at bedtime;  from Latin hora somni Kit Kat® bar A chocolate bar consisting of layers of wafers enrobed in milk chocolate  40  Word or Term Meaning LPN Licensed Practical Nurse, senior to care aide and junior to RN in traditional reporting relationship MS Multiple Sclerosis, a degenerative disease affecting the nervous system PRN Medication given “as needed” as opposed to those given on a regular schedule;  from Latin pro re nata Progress notes Legal charting completed by residential care facility staff members in digital or paper form Purée (diet), puréed (diet) Food that has been mechanically altered to a smooth, paste or pudding like texture to facilitate swallowing in dysphagia Quick sheets, cheat sheets Quick reference tools to help care aides save time in accessing information RN Registered Nurse, senior to care aide and LPN in traditional reporting relationship Shared responsibility agreement A written document indicating that resident or family agree to a care plan which is outside of usual or recommended practice, often used for residents who refuse protective garments or therapeutic/altered diets Social history Life story document, contains details about past life roles and family relationships TED™ stocking Thrombo-Embolic Deterrent (anti-embolism) compression garments for lower limbs Thickened (fluid), nectar (thick fluid) Fluid that has been thickened in texture by the addition of a thickening agent to facilitate swallowing in dysphagia Thin (fluid) Regular texture fluid, without the addition of a thickening agent UTI Urinary tract infection Word salad A symptom of loss of language in which words are mixed-up or used incorrectly, often a symptom of language loss related to dementia  Note: Glossary terms will be bolded in the text below, the first time that they appear.  What I Read  In the first theme I explore the digital and hard copy documentation sources of knowledge accessed by participants. In addition, the participants discussed which documents they used most 41  frequently for knowledge seeking and evaluated the merits of the different available options. This theme contains two subthemes: Preferred Documentation, which captures the participant reports of preferences for certain types of documentation and the role of these sources in communicating the needs of the residents between the team member and Usefulness, which captures how participants ranked the importance and value of different types of documentation and what factors made a source more, or less, useful. Progress notes were the most preferred tangible sources of information while documentation types that saved time, or were quicker to access were reported as being more useful to care aides during their shifts. Participant comfort with computer technology, as well as the physical locations of the knowledge source within the unit, impacted the perceived usefulness of each item. Participants spoke about many different types of documents that they accessed for knowledge seeking. The most of common of these were reported as Activities of Daily Living (ADL) sheets, progress notes, care plans, emails and social history documents. Throughout the interviews participants shared that they accessed progress notes and other documents both to find out information about a resident and to share information about a resident with their teammates. The use of documentation for information sharing is a complex concept which illuminates specific elements of care aide self-identity and ways of practice. These ideas are further explored in the Discussion chapter, under the heading Reporting as Knowledge Seeking.  Minor types of documentation mentioned during the interviews included posters, alert stickers, shift guidelines and other quick sheets.  It is important to note that Elder Enterprises’ homes use a specialized computer program for much of their documentation. This program includes profiles for each of the residents which contain demographic and historical data, a 24-hour report, and progress notes. Each unit within the homes contains one or more computers for the staff to access the electronic chart and 42  complete daily documentation. Reliance on computers creates certain barriers to the utilization of progress notes in regards to the ease of accessing technology and the amount of time required to do so. The barrier of technology is discussed below, whereas the more pervasive barrier of many forms of knowledge seeking, time, is reviewed in detail in the theme When I Have Time.  Preferred Documentation The two most preferred sources of documentation were progress notes (referenced 125 times during the participant interviews, making them the most frequently cited of all documentation types), and ADL sheets (the next most frequently cited source of documentation with 77 references).  Progress Notes. Progress notes were identified most often as a primary source of information required for care. When asked what sources of documentation she might refer to before caring for a new resident Lesley explained: I would want to check the progress notes before anything, because I need to know about the resident…. I want to know what kind of transfer they are. Are they resistive? Ways that you can kind of act and distract, that work, that are really effective. Things like triggers. Things that may trigger the resident. And then things like what kind of clothing they wear, if they are adaptive or not. (Lesley)  Jo explained the circular nature of charting in progress notes. She relied on what had already been documented by her co-workers to gain information about a resident, and in turn, she charted for the benefit of her teammates: If a co-worker has already met them, like the night before, we chart. So, once they come in we are charting our shift how this resident is, what the day looks like for them, so I can read off the last shifts. See what they’re like. And then I will chart on how my shift was with them, they can read it, the next person can read what’s going on and then we kind of gauge it and get lots of information. (Jo)  Reading progress notes was a priority step for planning her day, and she read progress notes immediately after coming on shift: 43  First thing in the morning, on the computer. Progress notes on the computer, with co-workers, because I want to know how my day is going to roll because if someone’s been up all night long, and they’re still up I know to go in there, give them a drink of water, offer them something, and if they fall asleep for the day at least I know they’re hydrated and fed. I will let them sleep and make sure their pad’s clean and then my day will be different than if they had slept through the night and I had to do full care and get them up too. (Jo)  All participants were in agreement that reviewing the progress notes is an important part of preparing to care for a resident: When you first come on your shift, especially a floor that you haven’t worked on before, the first thing I do is go in early and I’d be checking like, you know, the last progress notes to view what’s happening in the resident’s life right now. Kind of “Where are they?”… Like again, their transfers, their textures, all kinds of stuff. And your do’s and don’t’s, right? (Lesley)  Although Lesley is a full-time care aide on her unit, her views are consistent with those of Willow, a casual staff member: If I’m on a unit, like I said, I can go through the electronic chart and look through any residents, if there’s any changes. If I know that somebody has maybe been unstable for the past couple of months, I will look at the progress notes just to see if anything has changed. If we’re lying them down in the afternoon maybe, a little bit more, or if we have to elevate them a certain way. (Willow)  ADL sheets. ADL sheets were the second most commonly noted tangible source of information used by care aides. The ADL sheets are documents that are present “in their room” (Max), often at the bedside, and contain the basic information about care needs and directions: It basically tells us their routine for the day. Basically, what time they get up in the morning, what happens in the afternoon, what happens at night time, if they’re a ceiling lift. If they’re on our incontinence product system. What kind of texture food they eat, if they’re regular, if they’re diabetic. It gives everything so that when you walk in the room you know what you’re going into. If that person’s aggressive, if they have any type of issues… With elopement or anything like that. (Max)  One of the participants emphasized the role of these documents as a key knowledge source for care:  44  All the stuff that you need for the resident is in their ADL sheet…. You don’t have to go to a different source if the ADL sheet is always updated, right? You don’t have to go to a different source. (Relden)  The progress notes and ADL sheets were used by all of the participants on a regular basis. The documents provided care aides with information that was detailed and specific to their residents, making both progress notes and ADL sheets valued resources.  Usefulness Despite the stated importance of the ADL sheets, several care aides shared the challenges they experienced with these documents. They reported that the ADL sheets were unreliable at times, as the information on them was not always up-to-date. When the ADL sheets were out of date, the staff were confused, and sometimes incorrect care was provided. When asked about the documentation sources on her unit, Tegan explained that: For the care aides specifically it’s a written piece of paper. It’s called an ADL sheet actually and it hangs up in a resident’s either locked cupboards or their wardrobes in their bedroom… But typically like I said they’re not updated regularly enough. So whereas, like, we just hired a bunch of new casuals over the summer time and so many people’s ADL sheets hadn’t been updated that, like, they’re still trying to stand someone that’s been literally in a lift for seven months. (Tegan)  Tegan was not alone in her concern about out of date ADL sheets, as Willow illustrated:  Sometimes they’re not, it is very easy for them not to be up-to-date. I’ve gone to them many times where, of course I’m casual sometimes, or in previous times that I knew, so I come up to the floor and I, I always refer to the ADL sheet. That’s what they’re there for…. I’ll put on derma-sleeves that are in their room. There tucked away maybe in the second drawer but they’re there and it says put them on for days and evenings, take them off at night. So, I put them on and regulars, regular care staff say “Well she doesn’t need to wear those, you know? Just tuck them away in the drawer.” And I say “Okay, because it says on the ADL sheet.” So, I’m always referring back to the ADL sheet… because I can’t just assume they’re used or not used, right? I have to because that’s a document that we all go by. So, it should all be up to date, but like I said, they’re not all the time. (Willow)  Technology. All three facilities relied on a computer system to store much of their resident information including progress notes and some care plan documents. Overall, most of 45  the care aides felt that the computer system was an improvement from previous paper versions of documentation. Tegan summed this up when she said: I think of the people that have handwriting that you can’t even read, and you go back and you try to read progress notes from prior to computerizing it, and you’re like, “What does this even say?” So, I would say, huge improvement. (Tegan)  Willow went on to explain that for her, the computer system was easy to use, but she did recognize that this was not the case for all of her co-workers: It’s so easy to gain information. I know for some people, this is kind of the stereotype, but I know there’s a few older ladies that tell me that they have a hard time with typing, and sending maintenance requests, and things like that. So sometimes they ask me to do it, but I just, I help them do it because it’s their name attached to their request, right? And so I help them as much as I can. But, some people do find it harder just to be on the computer and say “Ok, where do I go? What do I click?” But with somebody like me, who’s very, very comfortable with technology and, I play around on the website a lot so I know what I’m doing and where to access certain things. (Willow)  Max expressed her own challenges with using the technology in her workplace: You know a lot of people are not as educated in the computer system, because, I mean I’m a little bit, but I’m not 100%. I’m a lot older than some of the younger people who know more better, you know, what’s going on. (Max)  Max explained that in an effort to address the care aide knowledge gaps around computer technology Elder Enterprises offered regular training programs and online tutorials. Max, however, did express some concern about her co-workers’ engagement in these educational opportunities: I think a lot of people get intimidated on progress notes because it’s, it’s permanent [laughing]. It’s there, you know? [laughing] So, I think it’s, it’s a lot of training. And I know they’ve trained a lot here, but it’s also those people being willing to go to those training sessions. And I’ve always said, and I know they do this now, you almost need an incentive for people to go to stuff [laughing]. (Max)  A common barrier to accessing the computer systems more often was time. This was particularly true when compared with the ADL sheets for sources of knowledge once a shift was underway and care was being delivered: 46  The computer, you might have to sit there and type in your information, it takes a little bit longer that way. Although it’s really good information, I just find it easier that you can, I can run to somebody’s room, check “Oh, are they general? Are they thickened? Ok.” And then I can run back out. (Willow)  Willow noted that the convenience of accessing the ADLs while out on the floor enhanced their useful for just-in-time knowledge seeking. Locations. Documentation sources were located in different areas throughout the buildings. In most of the units the care aides started their shift in a central area, such as the kitchen, which also contained the computer station and hard copy charts. On the dementia units the care plan documents, aside from the ADL sheets which were always in resident rooms, were also kept in these central areas. On the general units, however, care plans and social histories were kept in binders in the residents’ rooms, as Jordan explained: Well the computer is right in the kitchen. And the 24-hour report, we have like a little shelf with all the information. With all the books that we need…. Everything is in the kitchen. So, we can get access to everything. (Jordan)  While the central areas were noted as being a suitable location for information seeking at the onset of a shift, many of the care aides highlighted the convenience of the ADL sheets being in the residents’ rooms, as these could more easily be reviewed during the course of their day, and immediately prior to providing care. Regarding the ADL sheets, one participant shared: It’s the most accessible, I’m going to say, when you’re out on the floor and you’re busy. There is a lot of information on our network, on the computer….But most accessible, I’d say the care plan, because it’s paper form and it’s on the floor…. And it doesn’t take much time away from residents, doesn’t take much time away from your shift to sit down and look at it. (Willow)  Time was also a key factor in the preference for ADL sheets over other paper sources of documentation. Tegan described why she would choose an ADL sheet over other sources during working hours: The ease of access to it. Because I need, like we have everyone’s charts out at the nurses’ station. You know we’ve got seventy-eight charts in there, but you know, when you’ve got 47  charts that are this big [gestures 6 inches with hands] you’re trying to sift through everything and find all the information, you know, like we just don’t have time for that. (Tegan)   The participants reported that certain documents were considered more useful than others due to their physical locations. While many of the documents that the care aides valued were stored in central locations, participants explained that they were more likely to access the documents that were stored in the residents’ bedrooms during the course of their shift. Summary of What I Read The care aides in this study identified digital progress notes as their primary documentation source, however, they emphasized that it was difficult to find time to review progress notes during the course of the shift. Instead, the care aides preferred to seek information from the ADL sheets in residents’ rooms when working out on the floor.  Time, technology and convenience of location all played a role in determining the usefulness of any documentation. Comfort with the computer systems and the time required to engage with this technology were also noted as potential barriers to viewing and completing progress notes. While regular training was offered by the employer to promote the use of the computer systems, gaps in knowledge on the part of the staff members persisted. The locations of the documentation were also reported to be a factor regarding the usefulness of each source. ADL sheets were deemed to be used the most frequently during the course of a shift, due to their convenient location within the residents’ rooms. Overall, care aides expressed that they felt their employer made it easy for them to access the information that they required to provide their residents care on a daily basis from the numerous documentation sources available. What I Hear In this theme, the role of conversation and speech in knowledge seeking is explored. As a group, the care aides agreed that verbal conversations are a preferred method of knowledge 48  seeking and information sharing. The care aides in this study shared how they learned from others’ comments and examples. The vast majority of their descriptions were focused on conversations between the participants and care aide colleagues (43), other staff members (67), residents’ family members (60) or the residents directly (27). On two occasions the participants shared stories about learning from other care aides in practice, through experiences that involved listening in combination with observing. This theme is divided into three subthemes: Team, Power and Relationships, and Residents and Families. In Team, I highlight conversations with other team members. During their discussions of team dynamics, participants described the implications of interpersonal relationships on the accessibility of verbal information. In Power and Relationships, a number of care aides perceived power structures within the team that impacted the ease of knowledge seeking. In the last subtheme, Residents and Families, attention is drawn to the role of the residents in directing their own care, as illustrated in the participant stories. Knowledge seeking that involved families, as well as the perceived value of information provided by families is also included. Team  The majority of care aides described the conversations that they had with their colleagues as their preferred non-tangible source of information. A description of the flow of knowledge and power between different members of the team is provided in the Discussion section, Reporting as Knowledge Seeking. Care aides valued verbal communication with their teammates. Their stories illustrated the use of conversation on a regular basis throughout their shifts to gather and share information: We just talk every day with the other team members. “So, have you noticed this?” So we all know the people, and that someone’s changed, or something is happening, and you notice it. “I noticed this resident is doing this. Have you seen this?” So, I know it’s just constantly talking with the other team members. It keeps us all informed and up-to-date. So, with changes and things. (Jordan) 49    One participant stated that the opportunity to ask questions and receive immediate feedback was the reason for her preference for verbal knowledge seeking: So, you can either go on the computer or a lot of times I’ll like to get a verbal report. I prefer verbal, because then if there’s anything I need to ask my team or nurse, or whoever, then I can, right at that time. And yeah, and everybody’s on the same page. (Lesley)  So, you prefer verbal so that you can ask further questions? (Interviewer)  Mmhm. (Lesley)  Right away to that person? (Interviewer)  Yeah. If we can, discuss other things that are needed too, that maybe I’ve been meaning to ask, you know?... Like “How do I go about this? And who do I talk to?” (Lesley)  Other care aides. Although verbal communication with co-workers was the most popular source for information seeking by all participants, conversations with some team members were considered to be more valuable than others. Other care aides were named as the primary source for verbal communication because they were completing similar tasks. When caring for new or challenging residents, whenever possible, the care aides had conversations with care aide colleagues who had successfully provided care to the specific resident: …someone will cover the regular person’s two [days] off and they’ll get information from the care aides that are working that family. It’s all from like the network of care aides that we figure out how we do- like when someone moves from this side of the hallway down the other unit, they’re coming and asking the care aides about the information, not management or the LPN or the RN, because they’re not focussed in enough to really know those details…. When it comes to like the dirty part of the work and the actually doing part of the work it’s the care aides that you are going to want to go to… (Tegan)  Tegan went on to elaborate on the knowledge gap between care aides and nurses:  When it comes to, like obviously the paperwork and the legalities and stuff like that, then you’ll go to management, but as for the most part- I mean you’ll find that like there is an RN or an LPN here or there who actually knows a resident’s care needs, like to a tee, but the majority of them, they’re really not involved in that whatsoever… If we threw some of our RNs into a room to do the work of a care aide they would be so confused and they’d have no idea what they’re doing. (Tegan) 50    Some of the participants explained that they learned by listening to, and observing, other care aides at work. Lesley highlighted this indirect knowledge source: When I came out to work I’m like, there were times when I‘m going “I just don't know how to encourage this resident”. So I would stand back and watch other members of my team, and kind of go “Oh, ok well that worked. I wonder if I can make it work that same way?” So, then I would give it a try. And then there’s other times I just will brain storm something, you know? And think “I am going to give this a try then”, you know, one of my own ideas, and it’s just as effective. But a lot of it is just kind of, like monkey see monkey do, right? You learn a lot that way. (Lesley)  One participant clarified that discretion during listening and observing was particularly important when deciding which methods of caring to adopt from co-workers: I think with the knowledge that I’ve learned from my training and that I’ve gained in the past two years of experience, I think I have a good enough logic to know what to take in and what to leave out and say “I’m not going to do it that way”. There are even like, things like say, pad changes. They’ll say “Oh no, it’s so easy for you to do it this way, so easy for you to do in a certain way, and you can cut out like three steps.” But maybe that’s not the best way to do it, or the most sanitary, or the most comfortable. So, you know there’s things, “Yes, I do understand what you’re saying, but I’m not going to do that because it doesn’t work for me. It doesn’t work for my kind of, for my care. So, you just have to be smart about what care you want to give as a team member. Like I said, you can do like a really half cut job, or you can do it to the fullest of your ability. And it’s up to you as a person with what you want to do, or what you want to give to your job. (Willow)  Casual team members. Several participants described differences in knowledge seeking and access to information between casual and full-time or part-time staff members. Familiarity with colleagues and residents was cited as a benefit of being a full-time or part-time employee: Because I’m full time, or part time, I always work in the same community. Well the information like, comes and goes pretty easily. I don’t need to ask a lot because I’m used to working with the resident. When I used to work as a casual it was another different story. Right? Because residents change and you don’t have the opportunity to work on this same floor that often, so I came like half an hour before my shift, just to know. To gather information about the family I have to work with. So as a casual it’s harder in that way. Like when you don’t know. And, especially in the dementia unit, we always, if there is a new casual on we say “Well, these people need this.” We try to inform them, “This is here, ask for help if you don’t know this, don’t go with that person alone, call me”. Because I can read the face. I know, if this person says “No” just walk away… So as a casual it’s different. You need to gather all the information, every shift. Every time, 51  because it’s a new, different floor. When you are full time, you don’t gather information, because you can see the progress of the dementia, and all the changes in the residents. Because you see them more often, right? (Jordan)  One participant acknowledged that because she was a regular employee, her relationship with her co-workers made it easier for her to get the information she needed to care for her residents: Fortunately I’m so lucky to be in that environment, so, I'm coming at a totally probably a different perspective than what you’ve had different care aides, especially causals, because they don’t have the same, I don’t know, the same tightness I think…. I’m a regular on that floor so I can figure it out, where’s the casuals, crappy for them coming in high and dry, and it’s just, it’s a gong show…And then everybody’s down their throat. So, every time I see a casual and work with them I’m like “I will tag team with you, thank you for coming”, because I hate working alone. (Jo)  Max explained that care aides who worked on a casual basis may sometimes receive inaccurate information from residents or gaps in information that made their work more challenging: There’s a few people that, you know, they like to play it up a bit. And they like to get the attention. So, there are incidents where you are like “Ah, they’re working it because they’ve had to have casuals on”, or something like that…And the regulars aren’t there. The regulars know their personalities. They know that something’s not right. And even on a day-to-day basis you pick-up, you’re like “Something’s going on with that person.” You know like, “There’s something not right. I can’t put my finger on it but there’s something going on, that I don’t know what’s happening.”(Max)  And you’re seeing the changes based on your experiential knowledge of the resident? (Interviewer)  P: Mmhm. Of the resident, yeah exactly. Because when you’re a casual you’re all over the building, so you could be [in one area] for like a week, and you get to know the residents, and then you’re back somewhere else, and then you come back [to the first area] three weeks later, you don’t get, you kind of have an idea of what the resident is like, but you’re all over the place. Whereas like the regular staff really know inside and out. (Max)  Participants who worked on a casual basis described their reliance on verbal conversations with their colleagues for the most accurate and up-to-date information. The casual care aides expressed that they were intent on speaking with full-time or part-time employees:  I know what to ask when it’s necessary. I’m definitely not quiet about my work. I ask as many questions as I need to. But I think I ask, maybe, the right questions…. And when it comes to who, I know who to ask. I know if it’s something, depending on what I’m asking about the resident, I know who to go to. Maybe, if it’s a regular staff member, because 52  they are with them, you know, seventy percent of the week. Or if it’s maybe another casual, then I will just go to the LPN and ask them if they’re a regular LPN, because the information is key, right? Accurate information is what I’m looking for so, I just kind of see who I’m working with and will ask where it’s necessary. (Willow)  Tegan further illustrated the necessity of connecting with regular employees, and explained why these conversations were preferred over other documentation sources: I work casually, I’m all over the building. Care plans aren’t updated, on a regular basis. You know they try and stay on top of those things, but they’re really not, on top of it as well as they should be. So, it’s, more often than not I’m having to talk to other care staff maybe that are there regularly, before the documentation and the paperwork is actually updated…. Because I mean regular care aides they don’t even check [ADL sheets] anymore, which is why they probably don’t get updated as much because, you know, they come and they do this every day. It’s not like they need to be looking at this piece of paper every single day…So that’s why I think it gets overlooked so much, because it’s such a repetitive thing for them that it’s not in their brain that they need to check a piece of paper and update it because it’s, you know, their team. (Tegan)   Team communication. In addition to other care aides, the participants listed professional nurses, activity aides, occupational and physical therapists, dietitians and dietary staff, physicians, social workers, chaplains, educators and management, as their team members. When asked what makes knowledge seeking easier for her, one participant responded: Everyone being together as a team. Like everyone working together. It’s just not one person…. It’s everyone working together and, just communicating. And telling what they saw and what happened and, so everybody knows….I feel like when, either being nursing, activities, OT, I feel like we communicate very well as a group….I think it’s very important, and it flows. And as long as, I think, everyone sees everyone else doing it, it’s kind of like “Ok, I can do it”. And if you encourage other people to do it, like, when I orientate people, or when I have new casuals come on, and I’ll be like “Even though you are a casual, you need to know. You have to take on the responsibilities as well….Also if you don’t know if this is a normal thing with this resident, come talk to a regular staff member. Say ‘Hey, is so-and-so normally like this?’, and then we’ll be like ‘Yeah’, or ‘No, it’s not, you need to progress note on that’”. (Max)  Among the team members, Licensed Practical Nurses (LPNs) were identified by the participants as a primary source for verbal information:  My co-workers and the LPN. We’re the team…. generally, if I need any information we’re always, like I’m always talking to the girls, and like “Hey, this and this, and then”, so the LPN might be by the computer at the time and then she’ll be like tink-tink-tink [gestures 53  typing], and get all that stuff up we need, or send off emails we need to do so we’re all like working. Where I am specifically, thankfully we’re all working as a team. And we each do what we need to do to get it done for those sixteen people. (Jo)  At times, the LPNs were perceived as a bridge to information that was otherwise inaccessible to care aides:  The medications, we usually get that kind of information from the LPN. You know, she’ll say “This is what he’s on, this is what it’s for”. You know? “He’s on an anti-depressant, yada-yada-yada.” …I just don’t know nursing shorthand. So, you know, it’s all about the nursing shorthand, that kind of thing. And like we know, half, maybe a quarter of what you guys know…. Like what we need to know our LPN will tell us. (Ross)  Differences in scope or job role between the participants and their team members were perceived as a barrier to accessing accurate information. …the RN in our building is not a place I would go because they don’t do any care. Right? They don’t give out the pills, they don’t do to the care, they don’t clean up the messes, they are doing the paper work. And same with management. Management brings this person in, the RN does the paper work, but it’s the LPN’s and the care aides-, the LPN’s do the pills and the care aides are the ones doing the care, so obviously the care aides would be the first people I go to. They are. And the activity people at our building are good too because the way residents are off the floor doing activities, it’s good to see to how they are, because sometimes they’re like out of sorts, and they can’t do that, they come back. Or sometimes it’s like “Hey, did you know this person can play the piano?” Like those kinds of things. So, those are kind of the people I would go to. (Jo)  Power and Relationships  Multiple participants described internal power imbalances between different disciplines, between members of the same discipline, and within the team. At times, the participants reported that issues of power directly impacted their ability to access information.  As Relden explained, she regularly encountered difficulties with power imbalances at work: But every [unit] in that building, there’s always one that is the head. [Lists units], Every one, I could tell you every single of one of them. There’s always one strong-headed care aide. I could name every single one of them, because I work everywhere. (Relden)  Right. So, that person, do they have more control over the information, or do they- (Interviewer)  They want to be in control…Right? They want to be the boss. (Relden) 54   Does that impact how available information is to you, or how you go about getting information? (Interviewer)  …It’s just harder…Because then you have to take five, ten minutes to read the book instead of just your co-workers going “blah-blah-blah-blah”, its done…. Certain care aides and certain, you know, LPNs, and some of the full-timers like to have power trips. “I’ve been on this floor, I know more than you do.” (Relden)   Another participant, however, had a more complex view of why information was not always readily shared with the entire team. She calculated that elements of power and of work ethic created barriers to the flow of knowledge. When asked why she occasionally experienced difficulties accessing the information that she required for resident care, she responded: It tends to be because people don’t share the information that needs to be shared. (Tegan)  Who’s not sharing? (Interviewer)  Other care aides or LPNs. Because I mean obviously you know within healthcare it’s no secret that there’s people who are bullies, and stuff like that. So, there’s just no interest in helping out the other team members. So, it’d probably be from other care staff, is where there’s the barrier of information not being shared. (Tegan)  And why do you think the information isn’t readily shared? (Interviewer)   Just from my own personal opinion probably because people just don’t care. It doesn’t affect them, so there’s no point for them sharing…. Sometimes I just think that they don’t, there’s people that will hang up their cell phones, their phones from work, and they’ll just walk out and be like “Everyone’s good”. I’m like “Ok, well what does that mean?” You know. “You’re saying everyone’s good, so everyone’s had a poop, and they’ve all eaten and you know, or what?” And then, you know, you’ll go into report and find out from the LPN, you know this this and this has gone on in your family and “Everyone’s good” was actually just “Ok, I’m done with my shift, good-bye.” (Tegan)  This participant later elaborated on the role of power in dissemination of information: We have some registered nurses that think, “Well, you’re just care aides, and you don’t need to know this information.” They won’t have discussions with us because we’re just the care aides, you know, so they follow kind of like the hierarchy of healthcare, in a sense, where like the managers are on top of the RNs, and the RNs are on top of the LPNs, and the LPNs are on top of the care aides. So there’s no care aide talking to the RN. With some of the RNs. It’s not a blanket. There are some RNs that are back in that kind of thought process that like care aides are the bottom of the food chain. (Tegan)  55  Conversely, Jo did not believe that there were any power structures in play at her workplace that created blocks or barriers to accessing accurate or timely information. Instead, she explained that it was not always possible to access accurate information, as sometimes that information was simply not available to anyone on the team: Blocks no, wrong information yes…But then, you know, you’ve got to think a lot of these people are coming from the hospital. So, the hospital is the hospital. And then the RNs are getting the information from the hospital, so their charting is what the hospital told them, or what the family has told them. So, those are huge road blocks for my care because that’s not true. Like, not all the time, but some of it’s not true or they hype us up to say “Oh, it’s going to be so bad” and then you’re like “I love this person, they are great!” You know? So that part is definitely a lot of miscommunication there. (Jo)   On the whole, participants described power structures within the workplace that negatively impacted the effectiveness of their knowledge seeking activities. Many participants perceived that at least some of the information was blocked, or that they were intentionally misled by a co-worker in an effort to exert power over the participant. Some participants believed that miscommunication might also be attributable to lack of information, or lack of accurate information, on the part of the person who had more power than a care aide.  Care aide voice. Several care aides shared stories about specific instances in which they felt that their pursuit of additional information or assessments had been blocked due to the power structure on their units. In these situations, the care aides expressed frustration with the dismissal of their concerns by teammates in positions of power. One participant highlighted this struggle when she reported to her supervising LPN about a potentially infected wound: “So-and-so’s leg is so swollen. And it smells! And they got a cut here, and it smells like, it’s, ugh [grimacing] infected”, I said. And they go “Well, you shouldn’t be saying infected if you don’t know what it is, da-da-da-da-da-da”. And I said “It stinks!” That’s what I said. And she didn’t like it. She didn’t like it. (She said) “What do you want me to do?” “I just, in my own opinion,” I said, “it feels like it’s infected. It’s oozing and it’s gross and it’s colored green, the ooze, and it stinks.” And then she went all the way down there and she goes [sniffing]. She literally sniffed the fricking wound. I said “I told you it stinks”. She goes, “I can’t smell it”. I was like, I don’t know, I [don’t smell well] and I can smell the goddamn, fricking leg. It stinks…. But, we butt heads. It’s because, you 56  know, when I’m asked, and when I’m letting you know that so-and-so’s leg is swollen, and there’s an open cut, and its oozing green, and it stinks, smells foul, then you go do it! Don’t question me about it. Don’t make me say “It stinks”. Because I don’t want to say “It stinks”, [laughing] you know? “Go check it out.” (Relden)  On another occasion, a participant expressed concern that her opinion was not taken into consideration when the professional nurse responded to a change in her resident’s behaviour. In this circumstance, the care aide felt that she had a better understanding of the needs of the resident due to her daily contact and familiarity with that individual: The RN can come in and tell us all they want... But when they don’t see the change…. the care aides know what’s going on, because they’re with them all the time.… I feel like sometimes, there’s just not enough involvement with the RN’s. Like, or with even the LPN’s, because they don’t do care, right? …And it’s just like, when you’re not being listened to, when you do care on that person, that’s frustrating. And when someone comes in all authority and says “Oh, this is wrong.” Even a doctor will come in and say “Do this. They don’t need this.” And you’re like “Can you not? Do you do care on this person? Do you want to get scratched and bitten and hit with the metal lift?” Like you know, someone grabs it out of your hand and tries to hit you? There is a behaviour issue. They’re not happy. So, I think “The resident’s not happy. How horrible is it to feel that way that you need to lash out at everybody and hurt them when they’re just cleaning you up? And they’re just trying to love you and get you ready for your family? There is something wrong”. So, when we’re not heard about that, that pisses me off and I get angry. And like, that’s not fair, because that’s not fair to the resident. (Jo)  This experience of feeling unheard by supervisors was not unique among the participants. Willow shared a story about attempting to intervene in what she perceived as an unsafe circumstance for one of her residents. Willow felt that her voice and autonomy were negated due to the hierarchy within her unit: There’s this one gentleman who’s regular fluid but is eating a purée diet because he has no teeth…. He does well, drinks coffee and juice and stuff, but I worked a couple of evenings and then a couple of days right after. So then in the evening times I’m noticing at dinner time he started to cough, and he’s coughing quite a bit…. And so, on my day shifts when I got back, for breakfast I tried a thickened fluid with his oatmeal purée. And the LPN came up to me after she gives the meds and says “Why is he drinking a thickened fluid?” And I said “Well, I am just trying it out today. Maybe I should’ve asked you before but I just wanted to try it”. It’s not going to harm him to have thickened fluids, in my opinion, and so she says “Well he’s a general fluid, he’s a thin fluid. He doesn’t need it”. I said “Yes, but the past two evenings at dinner time he has been choking. Choking to the point where his face is purple, like, it’s scary. He is still coughing but his face is so 57  purple, and he’s out of breath, and I can tell. And so I’m trying this thickened fluid and she says “There’s no need to do that”. So she dumps it and gets him a thin fluid. I’m trying to advocate, which I think I’m doing the right way. But then I get this, like kind of, snobby reaction towards it. (Willow)  Willow explained that she used other routes to voice her concerns and described both the external and internal struggles that she faced in this situation: I told the LPN at that time, when she took away the thickened fluid and gave him the thin fluid again, which is kind of irritating, but you just keep it to yourself, you just have to, I told her I would just document every time I saw him choking because at a certain point he will have to become a thickened fluid…. I do understand that he’s only puréed because he has no teeth. He’s not a choke risk. But now that I’m seeing he may be a choke risk, then I’m kind of thinking it may make more sense that he should be thickened fluid. But they see him a lot more often. So, it’s hard to kind of speak up, because I’m a casual, so I only see him “X” amount of time. But I do see him starting to choke… And his coughing is really bad. So, it’s kind of hard for me as a casual to sit and then be like “Oh no-no, he’s a choke risk now”. Because they’re going to be like “No, he’s not”. And they’ve corrected me both times. They took his thickened away and gave him thin, so I’m kind of like “Ok. I guess”…I kind of feel silly at times because maybe I am wrong. Maybe, you know, maybe it’s not my place…but in my heart, I don’t think I’m wrong, you know? (Willow)  When asked if she had any idea why her voice was not acknowledged, Willow offered the following thoughts: I think it’s just because I’m not there as often too, maybe this happens quite often, maybe it doesn’t happen at all. I’m not sure, but I have to address what’s on my shift. The eight hours that I’m there I have to document what I see and what I hear, everything. And I have to document it…again maybe because I’m just casual, only there part time. But sometimes it feels kind of like nurses know better. Which they do have a lot more knowledge and training and such, but, sometimes it can kind of feel a little more, what’s the word I’m looking for? A little bit more degrading, maybe? (Willow)   As a group, the care aides appeared to value having their voices heard by their co-workers and by those in positions of power, and they clearly valued being advocates for their residents. The participants expressed feeling frustrated, and sometimes angry, when they perceived that their concerns had been dismissed. The most common issue that the care aides expressed was not being able to communicate to ensure the safety and comfort of their residents.  58  Staff relationships. Several participants described how interpersonal relationships with other staff members directly impacted knowledge seeking patterns and access to information. For example, as a casual employee, Tegan described experiencing greater difficulty in knowledge seeking when she did not have an amicable working relationship with her teammates: It depends on if the other care aides like you or not. Because I mean, if you have someone that doesn’t like you, you’re not going to see them or have any help from them whatsoever. (Tegan)  Ok. Does it affect information sharing? (Interviewer)  Yes. (Tegan)  Whether they like you or not? (Interviewer)  Yeah…. thankfully though usually if one person hates you there’s like three other people that don’t…So typically you can find someone that can give you a hand. But definitely that one person that makes it more difficult and doesn’t want to information share, or lend a hand, that definitely makes it a lot more difficult. (Tegan)  While Jo described having excellent working relationships with the other regular staff on her unit, she also recognized that open communication was not always guaranteed: I’ve worked with other staff members that are quite cold. I don’t know if that’s the right word, they are just very, they do their eight people, I do my eight people, excuse me. You leave the building, you’re done, right? Instead of going “Hey, you need help because that person is covered head to toe? I’m on it. I’ll help you out.” You know, that’s the kind of team we have on our floor. Yeah, so, makes it easier. (Jo)  Similarly, Relden described co-workers who were uninterested or unwilling to share information about the residents: I asked this particular person, that’s a long time ago when I started over there, the first thing she said was “Read the book”. I scratched my forehead, and I read the book. And since then, I don’t work with that person…. It’s just, she’s old, she been there a long time... Didn’t want to waste her breath I guess. But at the same time, you’re working with this person, what happens if there was an incident? Who’re you going to call? I would probably jump right away to the LPN for that situation…. (Relden)  Relden disclosed that she could not always trust her co-workers as a source of information. At times, she feared that some of her co-workers intentionally provided inaccurate details: 59  Because some people don’t like other people [laughing]…It depends on the person. Right? It depends on the human being. Sometimes they don’t like you and they don’t want to work with you and they just, make your life miserable. While their life is no better than yours. Yeah. It happens. I’ve seen it. (Relden)   Staff relationships, whether positive or negative, appeared to have a direct impact on the care aides’ abilities to access information through verbal knowledge seeking. While the participants described negative relationships that created barriers to information, they also described positive relationships that eased knowledge seeking. Staff relationships were also highlighted as a reason for knowledge seeking before or after regular work hours. This concept is explored further in the fourth theme, When I Have Time. Residents and Families  In this subtheme I gathered participant statements regarding information seeking from residents and family members. While residents and family members were considered to be a potentially valuable source of information, the accuracy of these sources was questionable. Care aides, therefore, could not rely on this information, on its own, and further knowledge seeking was often required.  Residents. While the bulk of the discussion about conversations revolved around interactions with other co-workers, many of the participants spoke about the residents’ voices, and how knowledge seeking occurred through conversations with the residents themselves: If the resident can answer me, I’d ask them “How do you generally like to do this?” A lot of times you’ll start a resident out with you know, say a.m., HS care, and they’re like “No, no, no. I don’t usually do my dentures this way, or this way”. “Oh, ok, well can you tell me how you like to do it?” Right? A lot of times they can tell you themselves… I don’t always want to do things a certain way, just because it works for me. It’s got to work for the resident as well, because then it’s just not going to work [laughing]. (Lesley)  Participants confirmed that residents’ voices were particularly important when it came to the right to refuse care. As Ross summarized:  60  The unit where I’m on they have the right to refuse. So even if they say no once, we back off. (Ross)  If a resident refused to comply with a certain aspect of care, refusal was considered to be a trigger for knowledge seeking. Relden shared a number of examples that illustrated this knowledge seeking reaction: Yesterday, she was wearing her TED™ stocking ok? And then today she said “I don’t want to wear my TED™ stocking.” Well, there’s a reason why she didn’t want to wear her TED™ stocking. So, if she didn’t want to wear her TED™ stocking today the first thing that you do is report it to the LPN. Let them know this person is not wearing a TED™ stocking, and ask “Is there a reason why?” So, then you let them know it’s probably because she’s in pain, right? It’s just a huge amount of communication with the LPN or your co-worker…. Sometimes, when a resident refuses to wear hip-protectors and they have hip-protectors in their room, and their [ADL sheet] says hip-protectors, and they refuse to wear them, the first thing I would do is ask the LPN, if they have a shared responsibility agreement with the family members, about the hip-protectors. And if they said “No”, I would chart it. And I would chart it on [electronic chart], I would write it down in the 24-hour [report]. I would let my LPN know the situation. And if they said, if they said they had signed the piece of paper, the risk agreement, I would like to see it before I do anything else. (Relden)  However, many of the residents had some form and level of dementia, therefore the participants described the need to assess cognition for each individual resident in their care. As Relden explained: If they’re cognitive they’ll tell you what to do… And you’ve just got to listen to them. And if you’re doing something wrong, they’ll tell you…. (Relden)  So how do you determine if someone is cognitive enough to direct their care? (Interviewer)  Because if you ask them questions they’ll answer you correctly. Like they don’t have word salad, right? So, they’re just automatically answering you, like answering your questions. (Relden)   Conversations with residents were a potentially valuable source of information for participants, but the care aides recognized that there may be concerns with validity. When possible, the participants took direction from residents. Informal cognitive assessments were 61  completed to assess the appropriateness of the residents’ directions. Regardless of cognitive ability, respecting the residents’ rights to refuse care appeared to be important to the participants.  Families. While family members of residents were identified as another source for verbal information seeking, the opinions of the care aides on the validity and usefulness of the information gained from family members varied widely. One participant explained that she valued information from family members as a way of getting to know her residents more on a personal level: Family members are the best information about the residents. I love talking to family members. Asking them “What was John like when he was younger? What was he into?” Or, “I can see that John likes pineapple. Is there a reason why?” You know, things like that. It’s really good to get to know somebody. And that’s why pictures are so lovely, when they are in their room. Lots of pictures of them, when they’re younger. Pictures of their family are good too, so you know if it’s a nice, loving family behind them and supporting them. But I love to see pictures of when they’re younger, or on their wedding days, or what they wore. What they look like, how old they were, things like that. Because it really, it changes the person that you see, right? You can see somebody that’s, you know, in a Broda® chair, that needs help with feeding and dressing and shaving. And basically everything. But you get to know somebody deeper, so that makes a big difference, I think, just to know who you are working with. (Willow).  As Ross shared, developing relationships with family members was an important part of her work, and at times made it easier to learn about the residents assigned to her: One of the things I do pride myself on with my job is I tend to be very close with the family members. And I don’t know if that’s just a personality thing, but, if you can’t trust me and you don’t like me, you’re not going to want me to take care of your loved one. So I really pride myself. I’m very close with a lot of my residents’ families. Like, you know, they walk in and it’s kind of like those “Eeeheeheeheehee!” [Arms up, waving] “I can’t believe you’re here! Yay, I haven’t seen you in so long!” You know? Big hug, and it’s like “Oh my God!” And I’m like that with a lot of them…. (Ross)  Do you think your relationship with the family members has any impact on the amount, or the quality, or the frequency of information sharing? (Interviewer)  Oh for sure, because they’re always coming in with new information for us. Like, you know, like they might have a memory, of, “Oh yeah, Dad used to love this kind of music. Play this for him”. You know? Or, like, “Yeah, Mom really did like that Elvis movie a long time ago”. Like, they’ll help us with little things like that, so the more that they come in the better. And they’re really great to have in there. (Ross) 62   Lesley shared a similar story and highlighted the value of the knowledge shared by families in improving the success of care interactions: If they have little pointers that they can give us. Especially if it’s a new resident and they’re going “Oh, you know my husband really doesn’t like to do this, but…”. Ok, for example, we had a lady who’d been living with us for about a month. She was brand-new to us and very resistant to care. But you show that lady a Kit Kat® bar and she will pretty well do anything [laughing], right? So lots of things. For example, her family would bring in Kit Kat® bars and that was the first thing they said was “You can use these”. And I’m like “Really?” And I thought “No way is a chocolate bar going to work”. Oh yes, what wonders that does! (Lesley)  Several participants, however, were hesitant to accept information offered by a family member at face value. The accuracy of information from this source was perceived as frequently flawed, for a variety of reasons: A lot of times family will give the information but it won’t actually be up to date. So a lot of times they’ll be like “Yeah, they transfer really well, with like a transfer pole”. But in reality they don’t at all, and they end up coming as like a full lift…. We get a lot of information from family. Family tends to kind of sugar-coat what’s going on with their loved one. I don’t know why. I think maybe they just don’t realize it themselves that it is at the extent that it actually is. Or, there is a fear of maybe not getting into where they want them to be, I’m not sure. (Tegan)  Jo echoed these concerns when she shared: I think it’s harder myself to deal with families then it is the residents, because the families are like “They’re like this, like this, and like this”. And you’re like “Ok”. And you just smile and you nod and then in the morning you’re like “They’re not really like that, but, ok”. So I’m very cautious on family information because their perception of their parent, or their grandparent is beautiful. Reality is not like that. They don’t need to know that they’ve dug in their pad all night and smeared the walls. They don’t need to know that part. They don’t need to know that they don’t sleep through the night and they’re screaming. They don’t need to know all that stuff…. You’ll get little bits of information, but I take it with a grain of salt…. I will take what they have to say, absolutely. And what they’ve written down about the way they were, 100%. But the way that person is now is the way that person is now. That is their moment. That is the moment I need to get into, and figure out. (Jo)  63  One participant who previously emphasized the value of developing close relationships with family members also displayed some hesitancy when asked if the information she receives from families is valuable: [sigh] Yes. But I will say that sometimes families get really frantic, and they kind of, over exaggerate, you know? So, you got to take it, whatever they have to say at face value. Like especially where there are family dynamics…. They make things sound worse…. Because sometimes, families don’t see straight with their loved ones. For good reason. You know, like, sometimes they just want to see the best, or they automatically want to assume the worst. So, I do listen to them, and I do believe them a lot of the times. But I kind of have to go by fact, not feelings. (Ross)   Participants spoke about the quality and types of information they received from family members. Although the information was perceived to be valuable because it allowed them to learn more about resident personhood, and sometimes made it easier to provide care, many participants suggested that the information provided by families was often inaccurate, and out of date. These participants reported that families were not always in touch with the actual care needs of the residents in a particular moment, and therefore, the information was not always useful. Summary of What I Hear  In the second theme, participants described conversations they had with other people such as co-workers, residents, and family members. I divided this content into three subthemes. In the first subtheme Team, participants described conversations with co-workers about the dynamics on their units and demonstrated the value of verbal communication over formal and tangible sources of knowledge. Verbal communication was perceived to be faster and more useful than other sources because participants were able to ask questions and receive immediate feedback. Unfortunately, at times, negative dynamics within the team created barriers to knowledge seeking via conversations. Casual staff, for example, were assumed to have less information about the residents and therefore were not considered to be a desirable source of knowledge.  64  In the second subtheme, Power and Relationships, team dynamics that impacted knowledge seeking were exposed. In general, the care aides in this study suggested that there was good communication between all disciplines on their units, although many of the participants acknowledged that power differentials could create barriers to communication between team members. Some care aides recognized that there were co-workers who withheld, blocked, or mis-communicated information in an attempt to exert power over others. Some care aides reported feeling frustrated when their voices were not heard, and shared stories that demonstrated how they had been blocked from advocating for the residents. Conversely, positive staff relationships increased the ease and frequency of knowledge sharing between the care aides and their co-workers.  In the final subtheme, Residents and Families, attention was focused on conversations between participants and residents, or residents’ family members. Care aides described needing to ask residents certain questions or engage them in conversation to check their cognition. If a resident’s cognition was deemed adequate, care aides would take some direction from the residents about how they liked things to be done. There was a wide range of opinions about the validity of information provided by family members. While some participants stated that family members were the best source of information and one of the only ways to learn about a resident’s personal history, the majority of participants admitted that family members frequently lacked up-to-date information about resident care needs.  What I Already Know  Throughout the interviews most of the care aides expressed that they often did not need to do any knowledge seeking because they were already aware of the information they required. In this section I explore the care aides’ additional ways of knowing, apart from direct and active knowledge seeking. Alternate ways of knowing described by the participants have been divided 65  into three sources (or three subthemes): their training as care aides (29) (Training), knowing standard practices in their workplace (18) (Experiences), and information gained by interacting with a resident within that individual’s own reality, or “world” (15) (Creative Genius). Each subtheme provides a unique perspective of one aspect of care aide identity. The care aides in this study viewed themselves as natural caregivers, with a specific set of training and job roles. They placed significant value on knowledge of job tasks, including industry-standards, worksite specific practices, and the individualized care that they provided to each resident for whom they were responsible.  Training Formal care aide training programs, as well as on-site courses and online modules were all identified by the participants as beneficial avenues to gain knowledge. For example, several care aides stated that they continued to use assessment and behaviour management skills learned during formal and informal educational programs. They emphasized that what they learned did not overshadow the importance of knowing each resident, and they tailored their approaches to every individual.   One participant reported that she used the assessment skills acquired during her initial training on a regular basis: Going back to school we learned that, you know, there’s the three things that you look for: their cognition, their physical ability and how well they’re actually understanding what you are asking them to do. And if they can’t do that you can always downgrade their care to, you know, so if it was a one person assist then you know you can either go two person assist or you can go ahead and put them in a full track ceiling lift. Yeah. So a lot of it goes back to the education that I got and how you kind of just go through those steps in your head, and if they’re not following along with that just downgrade their care. (Tegan)   Several other participants, however, reported that they did not use information from their formal training very often. Instead they adapted their approach from resident to resident depending on each person’s needs, personality, and preferences. As Jordan illustrated: 66  We have a dementia care training program. We use that. But it’s experience with the resident….You have to work every day with the resident to build that rapport and know likes and dislikes. That’s why it’s harder for casuals and sometimes they can’t do the resident. You have to go at the right time, and for this resident it’s “Well, they said ‘No’, wait five minutes in silence and then ask them again. They will say ‘Yes’.” So, I think it’s coming in every day and doing the same thing…. There are books, but no, by the book is another thing. You can’t pretend everything is by the book. Every person is in their own world. No resident is the same as another. And no resident is going to stay the same the whole time…. They can write all the books and signs, but caring for people with dementia is a day by day learning. (Jordan)  Lesley stressed the necessity to remain creative during her caregiving activities, because the approaches learned during her training program were not always effective: You can be taught things… like we’re taught a lot of gentle and persuasive approaches, and for others it might work really, really good, for both residents and staff. And in other cases, not so well. It doesn’t go over as well as what we anticipate. So, I just kind of think like “Oh, you know I wonder if this will work?” And it may be something that you haven’t tried before. You try that, and it may just be something real simple, and it works, right? So, I just try. I try and think a little more outside of the box and different things, right? (Lesley)  Most participants acknowledged that they recalled skills and theory learned during formal training programs, but were careful to clarify that prior learning only went so far. Familiarity with the residents and the ability to adapt to resident needs were noted to be more useful day-to-day than theory or training. Experiences  Experiential knowledge (knowledge gained from experiences as a care aide in a general context and when working with particular residents) was commonly cited as a reason why active knowledge seeking was not required. Participants explained that many tasks and transitions became automatic and part of their standard work practices. The exception was when care aides felt that there was a risk attached to making assumptions about the information at hand. For example, participants reported that it was important to “Cover My Butt”, and “Double-Check” at times, to ensure they were not held accountable for missing or inaccurate information. 67  Standard Practices. A majority of participants described becoming so comfortable and familiar in their roles that they no longer needed to seek information on a frequent basis. Casual employees, on the other hand, described being at a disadvantage because they felt less familiar with the residents and the standard practices, so needed to spend more time and energy seeking information. Events of physical violence, which may warrant knowledge seeking for management and prevention of reoccurrence, were not always addressed by gathering information. On several occasions the care aides concluded that episodes of violent behaviours were part of their jobs and therefore “standard practice”, not requiring further intervention or knowledge seeking.   One care aide described how much of her work had become automatic over time: It’s weird because I don’t even think about it, it’s just what I do. I chart, do this, do this. It’s the next stage, right? You need a full pad. You need next stage. Oh, you’re constipated? Right, ok, we need to give you prunes, right. Oh, suppository today, day four because we see in the bowel book you haven’t gone. Like it’s, it’s automatic…. It’s like any job you do, you learn “Oh, this person has had a fall. They’re not walking so well anymore, we better phone physio”. Like, you see that, so you just automatically “Oh, this has to occur”…. Like you just kind of, you just think that process, you don’t even, you just do the steps. (Jo)    Conversely, Lesley shared that she actively sought knowledge in an effort to learn about the standard practices of her work:  I would even go home and Google™ right? Like, “What is standard time?” You know? A person works in a facility, what is the standard amount of time that you should be taking that is also in like a humane way? Like we are human beings [laughing], right? I don’t expect the residents to do cartwheels because we need them to get going, right? (Lesley)   Despite feeling very comfortable in their roles as care aides, unexpected events did sometimes happen. For example, Relden described an event in which she was struck by a resident. She did not indicate that any knowledge seeking occurred as a result of this incident. Instead, she was somewhat dismissive, stating that these acts were a standard part of the job: You’ve just got to wing it. Right? You’ve just got to use your knowledge and put your guard up. It depends, if you are working on the dementia unit then you always have your guard up, at all times…. I will always be aware of where their hands are, their leg, or 68  anything at all. Because they can flip any time, right? They could change any time. Like last week I got hit right on the face, unexpectedly. And I’m like, I was even shocked! Because I’m changing the resident’s pants, whomp! [slapping across face] Right here [pointing to cheek]. I’m like “Whoa! [laughing] Where did that come from? Right? Because I wasn’t focusing, watching where the hands were when I was changing his pants. And it was my mistake at that time, right? But, it’s part of the job. (Relden)   Understanding of standard practices (gained through knowledge seeking, or positive and negative experiential knowledge), were reported by the majority of the participants. At times, however, the participants reported that it was necessary to seek or share additional information in order to avoid being held accountable for non-standard care. These participants used questioning techniques and double-checking to clarify information. The terms “cover your butt” and “cover my butt” were frequently used by the care aides to describe these activities.  For example, one participant highlighted how she used questioning to avoid making mistakes when providing foods and fluids: That’s the first thing I would ask when I go on the floor where there’s a new resident that just arrived. The first thing I would ask “Are they diabetic? Are they a falls risk?” …. (Relden)  So why are those your first two questions, diabetic and falls? (Interviewer)  It’s because of the fact that if they are diabetic and you give them sugar, the high blood thing goes “Whoop!” [gesturing upward]. Right? I don’t want somebody like that, right? Or, even if they go from being a regular fluid to a thickened fluid. You give them a regular fluid and out of the blue they’re choking. I don’t want to be the one [laughing]. You know? Like, then the first thing they will ask me, the LPN or the RN, will be “Why did you give that? Why did you not read the book?” Right? It’s best to cover my butt. Which I always do [laughing]. (Relden)  Max spoke about her role in updating ADL sheets, to provide other care aides with accurate information. We are responsible for basically all of them. We are responsible for updating them on a regular basis. So, if someone’s mobility has changed in the last few weeks we need to make everyone aware. If someone that wasn’t standing is now standing, or vice versa, we have to update that because if the regulars aren’t here and a casual walks in, and they were here a month ago and that person was able to walk and now can’t… And then they 69  go to stand them up and they fall on the floor, that’s on us, because we have to update the ADL sheets and state that “As of this date this person isn’t standing.” (Max)  Max described using multiple methods to pass on her messages, and emphasized communication as an important part of demonstrating to other staff members that she had met her duties and responsibilities: Communication is huge here. Like if you don’t communicate, if you don’t cover your butt and write it down in the 24-hour book, and the email, and the electronic chart then, you have to do everything because… even with maintenance requests I know, like I have to write down that a maintenance request is sent because we work on so many different shifts that one person might have done it two weeks ago and I didn’t know about it, and now it’s still not fixed. But did they send a request out? I don’t know. I’ve looked it up, it hasn’t said anything. So, I always write everything down. (Max)  Another participant described how she regularly double-checked the information she received from other staff members in case others provided inaccurate information: You just put it in the back of your mind and you still have to read the ADL sheet… It could be true, but at the same time you always want to check twice before you do anything else. (Relden)  And why do you double-check? (Interviewer)  Well, they might give you some different information. Then sooner or later you’re in trouble. (Relden)  As stated previously, this particular participant believed that some co-workers intentionally provided incorrect information, due to negative relationships and power imbalances.  Experiential knowledge accumulated over time as care aides became more familiar with the standard practices at work. Eventually some processes, including decision making processes, were described as automatic by some participants. Standard practices were perceived by these care aides to be an important benchmark; they investigated, asked questions, and documented information in order to achieve their goals and demonstrate accountability.   70  Creative Genius “Creative genius” was described by some participants as a way of engaging with a resident within that resident’s unique reality. According to these participants, they needed to acquire an understanding of what the residents believed to be true, and then they used this information to help them make meaning of the present reality. Max described how she tailored her approach to suit both the moods and the altered realities of her residents: If, you know, someone’s ticking you off and you’re just in that horrible mood because you’re just like “I am done with that person asking that 20 millionth question” [laughing], you know? Like, but you have to be like “That’s not bugging me today”. Or someone saying “I don’t live here anymore”. And you’re like, you have to be like calm, because they’re trying to get out, they’re trying to leave but you have to stay calm for them so that they will calm down…and they know when you lie. Like they know when you’re totally fibbing. So, you have to be able to come up with some creative genius to be able to tell them the reason why whatever’s happening in their life, because they’re living that moment. Like they could be in a war right now… (Max)  She then went on to describe an event that illustrated the alternate reality of one resident: We have red table cloths, and we have one member, resident, who thinks it’s the Nazis. So we don’t put those table cloths out around Christmas time. Or if we do, we have to redirect in a way like “Oh, it’s not. It’s just Christmas”. We’ll show her the tree, you know, because in her mind that’s red, what red symbolizes in her, from her past. (Max)   Many participants suggested that it was beneficial to adjust their approaches to match the personalities of particular residents. For example, one participant described purposefully altering her usual, more formal approach, to a brusque manner and informal speech pattern, in order to match her resident and foster a positive relationship: I found with her, the way she kind of would speak to me, and not necessarily like rude and swearing and stuff, but just “Oh, what the hell is the point of this?” Or something, right? A lot of times you have to speak to that resident just as they are speaking to you, just in conversation, right? … She wouldn’t like to give you her dentures. She would never give anybody her teeth to clean. And, something just as simple as “Can I get your teeth, so I can clean them? Or, “Can I get your chompers and I’ll give them right back?” Right? And just the whole thing rather than “Oh, hiii” [speaking in high pitch]. Because the sweeter you could be, a lot of times, the worse it’d be. (Lesley)  71   In addition to changing their approach, some of the care aides described assuming different titles or pseudo-titles in order to gain the trust of residents. Jordan shared the following example: One resident, I always say that “Your wife asked me to do your laundry, and your daughters”. So, I know the family a little bit, the wife and the daughter, and it’s important for them. “They asked me to do your laundry, and don’t worry, it’s paid for”. So, it all depends. So it’s like a little game. But it’s for a good cause, right? I’m not trying to play my residents. I’m trying to build rapport. One thinks I’m the boss. He says “I trust you”, and I say “Yes sir” [saluting], and all those things. You have to do that, right? (Jordan)   When the participants purposefully joined their residents’ realities, the underlying goal was always benevolence and they consistently described their desires to reduce distress for the residents, and encourage the residents to accept care. As Jo stated: You’ve got to read people. I find you have to get into their world. You have to become part of their world, not show them what you do. “This is what I do. This is my routine”. You can’t do that. You have to go into their world, and see what they want, and what makes it better for them. Because that’s, I have the rule in my head “Do unto others”. And I’d want somebody to go “Hey, you know, you’re ok. And I’m just going to help you. I’ll be your hands and your feet and your head when you can’t do those things”. And that’s my motto. Because I’ve seen it not done that way. Going “Nope, you get up at 7 o’clock because we’re dressing you and you are having breakfast, boom-boom-boom”. You can’t. I don’t do it that way. (Jo)  The success of this strategy was dependent on care aides’ familiarity with residents’ beliefs and abilities to find creative ways to insert themselves within residents’ narratives in ways that were acceptable to the residents.  Summary of What I Already Know  Throughout the interviews most of the care aides explained that they sometimes had difficulty identifying their own knowledge seeking behaviours because much of the information they used on a daily basis was already known to them, and therefore no further action was required. Alternative ways of knowing included reliance on previous training, standard practices 72  and procedures within their workplace, and being able to engage with residents who were experiencing alternate realities.   Participant opinions of the usefulness of their formal training programs and subsequent courses were mixed. Some routinely used processes and procedures learned during their care aide training programs, while others argued that formal training was of little use because they creatively and spontaneously tailored their approaches to individual resident’s needs. In summary, the art of caregiving was perceived by the participants as more valuable than formal training.  Experienced participants suggested that knowledge was gained over time, thus reducing the amount of new information they were required to seek on a daily basis. Many of the care aides reported that their decision making and knowledge seeking processes had become automatic. It was difficult for some care aides to distinguish knowledge seeking activities from standard practices. In an effort to meet standard practice guidelines some care aides described investigating industry norms such as timing benchmarks for completing care tasks. In order to be sure that they had met unit expectations, several care aides described “covering their butts” by asking clarifying questions and double-checking information provided by co-workers.  Finally, a number of participants described engaging in a resident’s alternate reality to reduce resident distress and resistance to receiving care. The care aides worked to appear calm to avoid upsetting a resident, adjusted their approach or manner of speaking to build rapport with a resident, and creatively assumed substitute roles within a resident’s reality. When I Have Time The concept of time was pervasive throughout the interviews and impacted patterns of knowledge seeking by the participants. In this section I describe the fourth theme in which I have divided the concept of time into the two sub-themes: Available Time which is focused on time 73  pressures and methods employed to save time, and Timing which is focused on the times when participants were more likely to be engaged in knowledge seeking activities.  The participants stressed that they routinely felt pressured to meet perceived care task timelines; therefore, there was not enough time for knowledge seeking activities during their shifts. All of the participants placed a high value on time management and emphasized that time management was an important and essential skill for care aides. Many of the care aides were engrossed in time management and described continually working to improve their use of time. Routine knowledge seeking activities were more likely to occur before, or at the onset of a shift, but some knowledge seeking did occur throughout the shift and in response to changes in the residents. At the time of a resident admission, a deficit of information frequently occurred, which resulted in increased knowledge seeking activities during this transition period. Available Time   All eight of the participants expressed concerns about feeling pressured for time when at work. Due to the fast work pace and unpredictable nature of their shifts, care aides stated that they struggled to find time for knowledge seeking. As one participant explained: It’s funny because [the manager] or [the supervisor] from the kitchen, everybody’s sending emails during the day. Or the guy from maintenance. We don’t have time to check our emails during our shift, like ten times to see who-. I do it, actually I do it in my home, at night time. Or in the morning, just do it on my own iPad. I just check everything that I can, and then read it here. (Jordan)  Max agreed, stating that she had no time during her shift for knowledge seeking, and that her best opportunity was: Definitely first thing in the morning. When we come on, I check my emails and I check the progress notes. I check the 24-hour book, and I check the day timer to see if there’s any appointments coming up because a lot of people will have, like a doctor’s appointment, or if there’s a care conference, or if the dental hygienist is coming in, or if, whatever… And then that’s my only time, really, because when I [laughing], when I grab that phone, and I go, I’m running until basically end of shift. (Max)  74  Mornings, however, were not a guaranteed opportunity for knowledge seeking.  Sometimes in the morning you do not have time to look at the computer, even if say it takes five, ten minutes. You don’t have time sometimes. You know, you get there, you drop your things, you know, bells are running. So… (Relden)  So, are you able to throughout the day? (Interviewer)  Mmhm. If you have a little breathing room, you know? And then some quiet time. Then that’s when you read the book with the life, all that stuff, right? But there’s no time. (Relden)  The care aides, therefore, were intent on fine-tuning their skills in time management. One participant explained how she had gone online to investigate standard time frames for various tasks: I was always, and I still am, very conscious of my time management. So, with me I’m like “Oh you know, if I have this many residents, how much time should it actually be taking me per resident?” So that I’m on a proper- like say especially day shift, because day shift’s crazy, right? Like you can’t be wrong. Like you’ve got to all click, and this and that. And make sure everybody’s up to the breakfast. (Lesley)  Max also felt pressured by time constraints. She spoke about the impact of this pressure: It’s all about the balance I guess, and just knowing what you can and can’t do throughout the day. I mean there are days where you’re just like, you’re ready to rip your hair out because you’re just like “I don’t have enough me to give to everybody”, and I’ve got like eight call bells going, and it’s just like, you do get stressed, you know? (Max)   She went on to explain that it was important to her not to bring her personal stress to work, and how she endeavoured to appear calm for the benefit of her residents: You have to check yourself every time you’re in a situation. And I know, like outside of here, life comes in. You try to not bring it in but you’ve got a lot of stress in your own personal life so, but you can’t bring that in. And you almost have to check everything at the door, walk in, and do what you’ve got to do to get your stuff done [laughing]…you just got to make the day more enjoyable I guess, for the resident. So that they’re not knowing something is going on. Like, I always remember in a course I did one time, you kind of have to be like a duck. You have to be calm and cool looking on the water, like you’re just floating, but you’re paddling like mad underneath that water. And I always remember that image and I always remember that’s how she described it to us because it was, totally it’s like you have to be cool as a cucumber, but you have to be like, just totally being, a mad person underneath because a lot of these people pick up on your vibes too. (Max) 75     Finding time. Time constraints created stress for participants and were coupled with the added pressure of keeping the residents unaware that the care aides were experiencing stress. Care aides worked to save time during their knowledge seeking activities when possible by multi-tasking, planning, and using digital documents and quick sheets.  One care aide illustrated how she engaged in knowledge seeking while completing multiple other tasks at the same time: It’s like, when you’re multi-tasking your work, for example, for the resident’s care, and you have a duty to do it, right? You’re balancing it up.… I might be making toast here, but I’m cooking eggs there and I’m doing laundry over there, and my nurse is talking to me [laughing, acting out each task]. You know? And then you go “Yeah, yeah. Ok. Nope, that’s not true,” [acting out multi-tasking] you know? On and on until you finish. It’s just big, huge, multi-tasking. Like, it’s time management, big time, and multi-tasking. If you don’t have time management and you don’t multi-task, your day is shit. Excuse me, my language, but your day is effed. (Relden)   Accurately planning routines was a frequently mentioned method of reducing time constraints. One participant detailed the competing tasks that she often had to manage during her shift, and stated that at times she needed to deviate from standard practices in order to meet time pressures and also ensure that the residents were safe: Every day we have a shower, or a bath. So, the day shift, because were doing two meals and every shower day we change the beds for the day shift and the evening shift, our time, like especially when it’s a full sling shower, it can be a mess. It can get out of hand. It can take you an hour. So, you really have to figure out what’s going on. That’s when you really have to have time management. And then you have to think of “Ok, I have two laser alarms for high falls risk. My co-worker can only do so much.” So, I have to go “Oh, I’m going to get these two laser alarm people up first, even if I have to wake them up, which is kind of against policy, but it will keep them safe so I have time to do this shower. And then they’re in the dining room, the LPN can watch them. I know it’s ok.” So, you have to juggle that time management. (Jo)  A small unplanned change in a regular routine could result in significant upheaval, and time shortages: We have a few residents who are independent on their appointments, they book their own appointments. They need to let us know. They need to write it in the book. They can’t be 76  like, ten minutes before their appointment “I need to go to the washroom, because we’re going out for an appointment”. It’s like, “You kind of have to tell us that a few days beforehand”, because we’ve got our routine on how to get things done. You throw us a little kink into it, and we’re gone for the day [laughing]. Like, we have everything down to a science (Max)  Quick sheets and amalgamated computerized files were noted by one participant as quick and easy sources for knowledge seeking: Everything’s on the computer, so that makes it so much easier. And the 24-hour report, the notes there. Like instead of me looking in the bowel book for when people are showers somebody writes “AM.” or “PM” so I know when the showers are and when to change the bed. Saves me so much time. The dietary binder we have, the front page says who’s puréed, minced, right away. You don’t have to look at every little individual thing just to make sure nothing’s changed. So, lots of little things like that I can go to and figure it out. (Jo)  So, the computer and the quick sheets are more helpful for you? (Interviewer)  Yeah. Especially because I do the same floor all the time, right? So, and then I’ve made a folder for the casuals, so they know what people drink, right? So, when they pour drinks they don’t have to go through every little page and go “Oh, this person likes cranberry”. It’s all written down on a cheat sheet for them so they can just go. Just things like that to make it faster and more efficient because you don’t have lots of time. (Jo)  Despite their varied efforts to manage and save time, most participants described how there was never enough time for knowledge seeking. The majority of the care aides worked to maximize their time for knowledge seeking by completing multiple tasks at one time and by strategically planning for knowledge seeking. Timing  All of the participants agreed that there were a few specific times when they were more likely to be knowledge seeking. In order to frontload information seeking and leave more time for care of the residents, all of the participants reported that they were most likely to gather information at the beginning of their shifts. Many of the participants (5) stated that they also sought information as needed throughout their shifts, or immediately prior to delivering care (4). The majority of participants shared that they are most likely to seek information in response to a 77  change in residents, such as a decline in condition or a new behaviour (7). Seven of the eight participants described making extra time for information seeking by engaging in knowledge seeking activities outside of their regular work hours. Finally, seven of the eight care aides reported that there was a greater need for knowledge seeking when a resident was newly admitted, as they were likely to have a dearth of information about a new resident.  The participants, however, were not comfortable with waiting until the last minute to obtain information. Instead they tended to engage in knowledge seeking whenever the opportunity presented itself.  After hours. All but one of the care aides in this study reported using their personal time to gather information outside of regularly scheduled work hours. These activities included engaging in online investigations, checking emails and texting or talking to co-workers. There appeared to be a correlation between knowledge seeking outside of regularly scheduled work hours and positive interpersonal relationships with co-workers.  The purpose of using personal time for knowledge seeking was to save more time during the shift for resident care and job duties: I prepare myself on my own time, or even when I’m driving. Or when I’m outside having a break. I like to think ahead, I would say. “What can we do?” Right? “What should I do the next time that I go back on that floor?” And then sometimes you hear from your co-workers that are on that floor, they tell you. Or if you need any other information, you ask, right? Then when you go on that floor at least you know what you’re walking into…. I like to get the information myself, ahead of time, before I go on that floor. Because then I prepare myself. But if I go in there not knowing anything about (a new resident), I’ll be looking at the book (care plan). Taking more bloody time reading those books [laughing]. (Relden)   One participant explained that it was sometimes necessary for her to use her personal time to search online for information related to residents’ health conditions: I have to kind of do my own, sort of, figuring out what the illness is and I’d probably have to go on my spare time, when I’m not at work, and be like Googling or reading like medical journals and stuff like that to find out about it. It’s not readily available usually. 78  If it’s something like super, super rare, that we don’t see very often, they’ll print out like an information sheet and they’ll attach it to their file. But if it’s something a little more common that you see, I usually have to do all of the work to figure it out. (Tegan)  A number of care aides also felt that it was important to arrive early for work to speak to other care aides prior to the start of a shift, especially if they had not worked recently on the unit. As Jordan explained:  Sometimes you go on your vacation and things change. You have to come early and talk about what has happened with all of the residents. Yeah. (Jordan)  So, if you’ve been away for a little while do you tend to come, like, before your shift starts? (Interviewer)  Yeah, of course. We always do. But if I was on vacation I come like 20 minutes before so I can talk to all the people [laughing]. Talk about all of the residents. In general, like, things have changed…. So, we have to put our time in, in order to get informed sometimes. At least to have the information we need to start our shift. (Jordan)  Some described accessing work emails multiple times a day, every day of the week: We have work emails. And so like, I’m just speaking for myself, I check my emails pretty regularly throughout the day. Even on my days off. Just to kind of stay up to date so that when I come back after my two off, I kind of have an idea of what’s going on. So, I check my emails outside of work. (Tegan)   Care aides were more likely to access information after work hours if they were experiencing close and positive relationships with their co-workers. For example, several participants stated that they spoke to, or texted with, their co-workers during their personal time, in order to share information about the residents. One participant shared how she communicated with her co-workers after hours: Both girls that I work with, were texting back and forth. If something happens during the day when we’re not working, were texting going “Hey, this happened.” You know? “Heads up when you come on your shift because I’m off”. So, lots of communication… (Jo)  Knowledge seeking behaviours outside of regularly scheduled working hours also seemed to be associated with maintaining positive interpersonal relationships between co-workers on a unit: 79  So that person to person communication is happening even when you’re not at work? (Interviewer) Yeah, just because we are, we’ve become friends, right? And it’s good. Yeah, there’s actually quite a few girls there that, they’re my friends now. They’re not just my co-worker friends. (Jo) Before you kind of had this cohort of co-workers that were just readily sharing this information, was that something that was important to you? Like getting up to speed before you come to work? (Interviewer) No, it just kind of happened. (Jo) Ok. So, it’s not a necessary part? (Interviewer)  No. (Jo)  While some of the care aides came to the units early to gather information, others checked emails from home, or communicated with their co-workers, often by text messaging. Overall, the intent of knowledge seeking outside of regular work hours was to save time for resident care during a shift.  Admissions. Seven of the eight participants indicated that they were often concerned about a lack of accurate and up-to-date information and a lack of available information, especially regarding new admissions. Tegan explained the usual processes for sharing and seeking information about a newly admitted resident: Management sends out a, like a getting to know them kind of email. So, once they send out that we are getting a new admit, they send out an email with all the prior information from family. Or if they come from hospital, they have kind of a breakdown from the nurses from there. But other than that, we kind of have to just, figure it out. A lot of times family, family will give the information but it won’t actually be up to date. So, a lot of times they’ll be like “Yeah, they transfer really well with like a transfer pole”. But in reality, they don’t at all, and they end up coming as like a full lift. So, a lot of the information we get is very old. So, for the first three days we have like the, you know, the watching. Where we do a lot of the close watching. Like progress notes, and stuff like that too, to be able to build their care plan later in the week after they’ve been there for a few days. (Tegan)  Of greatest concern to participants was an apparent lack of information about new admissions or a lack of accurate and up-to-date information for the provision of care and a smooth transition for the resident into their new home: 80  A lot of the times, like especially when they move in, like I said, they don’t have as much information, as would be nice…It kind of seems like whenever we get someone new it’s like we are starting completely from scratch. It’s like no one has any idea…. That first bit of their moving in and the information that you get then, that’s kind of detrimental towards you know, their happiness, with the transition into residential (care). Because, I mean it’s not easy, obviously, you know, moving from your home into residential care. It would make their transition a lot smoother. And easier, you know, obviously on the care aides, but smoother for the resident, if their information was completely up to date, and as descriptive as possible…And not sugar-coated from family or from you know [the hospital], or from another care home even. You know like, as much as it sucks we need the honest truth all the time. (Tegan)  One participant explained that a gap in knowledge may be unavoidable, as some aspects of a new resident’s care are not known at the time of admission:  Depending on the resident. Depending on their cognition, depending on, you know, if their meds are good then you can dig. If they’re still being all tweaked and the behaviour is kind of like, a little crazy, you kind of step back and just get the care done. Get them adjusted and just like wait. And then just kind of see what your co-workers, yeah, you just brainstorm back and forth. Yeah, and you got to remember we’re dealing with sixteen people at the same time, doing breakfasts and lunch so there’s not a lot of time to like sit down and try to figure this out. You just kind of go with their day and they go with your day, and you just ride the wave and see what happens. And then the routine, in a couple weeks the routine becomes apparent. (Jo)   Jo described the inaccuracies of information regarding a newly admitted resident, as a result of changing conditions or miscommunicated messages. At the same time, she adamantly denied that any information was intentionally being blocked or filtered due to power structures, as other care aides had previously suggested:  When people come in, you got to give them a couple weeks. Even when they come back from the hospital if they’ve gone from walking to breaking a hip, or an arm, it takes a couple of weeks for them to readjust to their new meds and then a new way of life…. So, the nurses are, the RN or the management, everybody’s getting information that is all not the way it’s going to be when they get there. So, I don’t think it’s, we’re not being blocked. We are not being misled on purpose. It’s just all these events happen and until they are where we are, you can’t, all the information I get is, that’s why I say until I get to know them I take it with a grain of salt. (Jo)   81  Relden explained that she did not always have adequate time to review the care plan before meeting a new resident. Instead she would attempt to look over the information while the new resident was briefly distracted: Well, if they’re in their room I will read it if I have time to read it. Right? But if they’re right there and sitting beside you I would just introduce myself right away. Who I am, that I’ll be looking after them, and then I’ll offer them something to distract them, and then I’ll go read it quickly. (Relden)  Changes. Participants shared many stories about times when they had engaged in knowledge seeking in response to changes in residents. The types of changes that were observed included changes in behaviours, facial expressions, health conditions and abilities, or changes in the ways they interacted with care aides. Relden described seeking information using trial and error during successive attempts to calm one of her residents whose behaviour had changed: The first thing is you come in, you walked in and they’re sitting in the dining room. The first thing you see is something’s different with this resident. Like for example, this person is pacing more than normal. The first thing I would do, I would talk to the LPN. You know, “Why is she agitated, or is he agitated?” Like for example, we had one today, and the first thing I did was try to communicate with this resident. And I asked if- there’s only three things, that keep them pacing back and forth or pissed off or angry. Either they’re hungry, or they need to go to the bathroom, or they want to go to sleep. Or they’re wet. Those are the only things that trigger people, right? Or, sometimes, when another resident also, you know, is pacing back and forth like that, try to figure it out. “Why are they pissed off and why are they pacing?” (Relden)  Another participant also described how a dramatic change in a resident’s behaviour triggered a knowledge seeking response: I approached her a little while before and she was fine and then I approached her later and she just like freaked. Like absolutely freaked. And it was like she was a totally different person and I thought “What the-? Like did I do something wrong? Did I say something?” …. But that was the time where I had to kind of stop because you know “I can’t really go any further here because I’m not really sure what’s going on”. But I knew something wasn’t right. Then I thought like “Is there an underlying condition, like a health condition that may be happening right now that, you know, we’re not aware? Or this is something that, you know, this resident has actually been diagnosed with?” So, first thing I did was go see some nurse who would look at her, her health conditions and I found that (bi-polar disorder). And I thought right away, I kind of went “Ok, I am kind of understanding now where this came from”. And then just makes you look at things a little 82  bit differently, right? It’s not just the person just in a bad mood, right? It’s not just your resident in a bad mood, there’s a reason for that behaviour, right? (Lesley)  One specific knowledge seeking activity described by the participants was observation of residents’ facial expressions. Lesley spoke about the changes in facial expression when her resident “freaked”, in the example above: Just in facial, like in the eyes. The eyes were a lot different and, it was just, it was, I’ve seen her upset and a little agitated. This was more extreme. That’s why I kind of knew, like, it was just totally out of the ordinary and I hadn’t seen it before, so I questioned it before I proceeded with anything else. Just for safety, right? Hers and mine. (Lesley)   The majority of participants described noticing changes in residents’ eyes or facial expressions, and that these changes signalled a time when they needed to gather more information: We have some residents, their eyes change. Like, when they’re happy [opening eyes wider], or when they are in a pleasant mood. And when they don’t want to, just, it’s a cold [narrowing eyes] way they look at you. Like cold, like no feelings. So, just ask some other questions and if the person says “No!” you say like, “Ok”. Just try to walk away. (Jordan)  Ross shared a similar description of changes to the eyes and facial expressions, and acknowledged the role of familiarity in noting these changes: We have a couple guys and they’ve got those eyes. They’ve got those eyes that you do not trust. And, yeah, you’ve just got to watch. Some of them yes, you watch their facial expressions. Some of them just look [laughing] miserable all the time, so that’s like, who they are. But some of them yes, absolutely you watch their faces. (Ross)  Ok. So, is that something you can tell about someone when they’re new, or do you have to know them before you can tell? (Interviewer)  You have to know them before you tell. There’s one guy who came in though, and he just, automatically we were like “Watch that guy’s eyes”. (Ross)  Can you describe what that is you’re looking for? (Interviewer)  Absolutely not… I don’t even know. He’s just got this look, it’s like “Oh, he’s going to snap”….We had one lady that, whenever she was going to hit she’d, she’d quiver her lips. So, you knew whether to duck or not. And she’d be like fine, all of a sudden she’d go [quivers lips] and you be like, “Ok, she’s going to get me”. (Ross)  83   Accurate interpretation of a resident’s behaviours and facial expressions was a particularly important component of staying safe and reducing distress for everyone involved:  Like we have a lady on right now, for instance, she was supposed to be my shower yesterday. It was the first time I’ve ever met her, last thing I was going to do is shove her in a shower. I was going to, like, ride her out, see what care was like and go from there. She wasn’t ready for it, so I wasn’t going to push it. (Ross) Ok. And how could you tell she wasn’t ready? (Interviewer) She was very uncomfortable, very cold. I didn’t know much about her. I did learn later that that’s normal behaviour for her, but because I wasn’t used to it, I backed off, until I learned more. (Ross) Ok. So, you’re guided by how much she’ll engage with you? (Interviewer) P: Yeah. Yeah, and how she can communicate with me as well. Some of them can’t communicate, some of them, just get angry. So, you just kind of read. Read them. (Ross)  When Willow experienced difficult interactions with residents, she stated that she would question her co-workers. Questioning as a knowledge seeking activity enabled her to learn about a resident’s preferences and improved her chances of success when providing care: There shouldn't be a reason why, let’s say, care isn’t smooth. There shouldn’t be a reason why things should be difficult for either the resident or the team members. There’s a gentleman I worked on the unit with last night, and I’ve worked days and evenings with him plenty of times. I know this gentleman quite well. I know there are certain things that he likes, just because, regular care staff always tells me the little tidbits, and “Oh, he really likes ice cream cones. If he’s ever agitated or uncomfortable, give him that and he’ll sit there, he’ll eat it and he loves it, and it’s great”. And so, those are the little things that can make care smooth, or can make his evening a little bit better. (Willow)   Changes in a resident’s health status or physical abilities also triggered knowledge seeking: I’ve gone for couple days and then you come back and they can’t stand very well. So, then you email physio and say “Hey, can you assess?” and they’ll try to walk them, if they had a walker or they’ll put a pole in their room so we can transfer them more. (Jo)  So, if you’re seeing those physical changes, are there assessments that you do? Or do you go immediately to getting help from nursing or physio? (Interviewer)  84  If there’s been change, like that, so definitely a change from they could get out of bed and stand up with their walker going to the bathroom to you’re using, you’re transferring them, you’re pivoting transferring them, you definitely chart on that. Tell the LPN and then I have to send an email to physio and physio comes and re-assesses to see what other tools we can use for them. If they need to be on a walking program, or you know, whatever program they need. Yeah, so we change the equipment as needed.  (Jo)  A decline in a resident’s physical abilities also triggered knowledge seeking activity:  We have one lady who just recently was one of our pretty much independents. She pretty much did all of her own care on her own. Literally within like a week she just started sliding. So, the first thing I noticed with her was she wasn’t able to follow direction. Which is very unusual for her. She would be the one to come out, make her own breakfast. But little by little you would notice that she would stop and she would just blank out. Like she’d go to make her toast and she’d like just stand in front of the toaster and not sure what was going on. So, from that kind of cue, I took, “Ok, now we need to start checking on her care. If she’s forgetting to do this, what is she forgetting to do with her care?” … And then the next day when I went in, I went in and I checked on the floor first, before she was able to come out, to make sure she had proper care. Watching her while she brushed her teeth to see if she was able to follow cues, do all of her regular ADLs. (Ross)  Finally, physical signs of health changes, such as damaged or unhealthy skin triggered knowledge seeking activities:  They could have like a pressure ulcer. Anywhere in the nether regions. Redness. Chafing. (Ross)  So, if you saw any of those physical things then, what would your process be to try to get information? (Interviewer)  Well first we would report it to the RN or to the LPN. Someone could have already reported it so there could already be like, like a cream or something on the way, say if it’s an open area or whatever. If there’s a bruise or whatever, go back and see if there was a fall, if there was a fight, if anything had happened. (Ross)  Ok. And so, when you’re reporting it to the LPN, what’s you intention with that reporting? (Interviewer)  Well I think it would depend on what it is. Like, if it is a fall, then we need to figure out why they fell. Did they trip on something? Did they trip on a crash mat? Are we not getting to them on time? Are they weak in the morning? Are they weak in the afternoon? Again, if it’s an open sore, we report that. Creams, whatever, that will be ordered. (Ross)  Participants described how they would often report to the LPN about changes in residents’ conditions in an effort to instigate further investigating by the LPN, or to gain knowledge from 85  the LPN. This phenomenon is explored further in the Discussion section, Reporting as Knowledge Seeking. Fluctuations. While changes in condition and behaviours were highly likely to result in knowledge seeking activities, the participants were sometimes hesitant to over-react, because fluctuations in residents’ presentations were common. Many participants described checking with their teammates to determine if they were the only one noticing a change. Most participants expressed a desire to verify their assessments with their co-workers in case extensive investigations were unwarranted:  So, doesn’t matter if my resident has been, like, calm for the last eight months. Like I have one resident that always hugs me, and it was great. And for the past two rotations he has changed. He’s aggressive, he’s resistive, so he’s changed. So, I have to, when I notice like “Uh oh, this is new, he’s never said this”. So I talk with the other person... “Have you noticed this?” And also to the morning person. We are just gathering information from all other care aides that work with him and seeing if he’s changing just with me, or it’s just one day, and we just try to see.… So, we just talk, and we are always prepared because it’s a dementia unit, so, all the residents, they are not the same every day. Some are, like calm, but when you have an unpredictable resident, every day could be different. Right? One day is like “Wow, score! He let me do everything.” And the next day he would try to hit me, or something, so every day is different with some residents.  (Jordan)   Max confirmed that it was important to determine if the change was persistent before seeking knowledge about the situation from nurse supervisors: You want to be able to know if there’s a pattern, if this is something that’s changing in their cognitive level, or if it’s something that’s just temporary. Or are they rocking a UTI, and you know, their behaviour has changed because they start seeing like the trees moving in the in the picture behind you? (Max)  Max would sometimes choose to observe her residents over time, in collaboration with her co-workers, to be clear that what she was seeing was not merely a fluctuation in presentation.  If it’s not a huge thing, like 911, like I don’t know if it’s me, or it’s them or whatever, I’ll email my other co-workers, my other care aides that I work with and I’ll be like “So, I’m just letting you know that so-and-so is acting really weird. Do you think you could watch them on your days that you’re on that side? And then when I get back from my two days off we’ll talk about it and we’ll figure out a plan?” And if this is a normal thing, you 86  know, I don’t want to red-flag it right now, but my red flags are starting to pop up because something’s going on. (Max)  Knowledge seeking was triggered when participants witnessed changes in the residents. The participants described reacting to changes in behaviours, facial expressions and conditions of the residents. Fluctuations in resident behaviours and conditions were common, however, a number of participants described being cautious about overreacting to temporary changes, and focused their knowledge seeking activities after thoroughly confirming their observations with co-workers. Summary of When I Have Time   The care aides in this study described having insufficient time to complete knowledge seeking tasks as often as they would have liked. The fast-paced and unpredictable nature of their work created barriers to accessing information during the course of their shifts. Due to these time pressures the care aides explained that they were constantly thinking about time management, and that effective time management skills were highly valued in their teams. Not having enough time to learn about residents resulted in participants feeling stressed and sometimes overwhelmed.  Participants shared stories about the various strategies that they employed in their efforts to save time. Multitasking, use of quick sheets or bedside care plans, and meticulous planning were all noted by the care aides as useful techniques. A number of the participants stated that they sometimes felt a need to contravene standard practices and policies in order to have enough time to complete care for the residents.  All of the care aides agreed that they preferred to frontload their knowledge seeking activities before, or at the onset of, their shifts so that knowledge seeking did not interfere with their abilities to provide required care to the residents. When frontloading of information was not 87  possible, the care aides used multitasking techniques so that they could engage in knowledge seeking activities during brief moments of freedom from caregiving.   Seven of the eight participants stated that they regularly sought knowledge about the residents outside of their regularly scheduled working hours, in order to be adequately prepared for their shifts. They checked their work emails from home, they arrived early to work to read documentation or speak with their co-workers, and they texted with other staff members outside of work hours to obtain information about the residents. Positive interpersonal relationships with co-workers increased the likelihood that some participants would engage in knowledge seeking after work hours.  When residents were newly admitted, all but one of the care aides expressed that they were required to engage in more knowledge seeking than usual, as there was often a lack of up-to-date and accurate information available. Due to the transition period after an admission, the participants recognized that some information, such as residents’ current cognition or abilities, needed to be learned over time. This resulted in a heightened period of knowledge seeking as the care aides gathered information about the new residents from all available sources.  Finally, the participants clearly initiated knowledge seeking activities in response to significant changes in the residents. These changes included changes in resident behaviours, facial expressions, mobility status and general abilities. Most participants acknowledged that resident presentations often fluctuated so all changes were not necessarily significant. In order to determine if further information was required, most care aides engaged in joint observations and assessments with their co-workers. Changes that persisted over time were considered to be significant and warranted further knowledge seeking.   88  Why I Seek  The final theme, Why I Seek, is an illustration of participant motivations for seeking knowledge about the residents. The care aides in this study described a natural drive for caregiving, or innate understanding of how to care for others, that included knowledge seeking. All were highly driven to provide safe, quality care to the residents. They recognized knowledge seeking as an important part of being prepared, and a necessary step in providing high quality care. The question of “What is right?” in terms of care that should be provided to any human being, particularly vulnerable elders, was carefully considered by the participants. They examined situations from the perspectives of seeing themselves as residents or family members of residents, or by imagining their own family members as residents. These reflections motivated the participants to seek knowledge required to provide appropriate care. This theme is divided into three subthemes: Natural Caregivers, Preparedness and What is Right? Natural Caregivers The participants described themselves as having particular qualities which influenced their knowledge seeking activities. Some referred to an innate drive to help other people while others referred to an inquisitive instinct that included gathering information necessary to provide care. For example, Max described how a passion for the work propelled her to seek knowledge about residents: I would say I need to know everything [laughing]. (Max)   Ok. Do you think that’s typical? (Interviewer)  No. I think it depends on the care aide too. It depends on the passion, I guess, maybe. I’m here because this is their home. I’m here to help them. I’m here to assist them. This isn’t a job for me. This is their home. I come into their home. I’m looking after them in their space. So, and I always remember that…. There’s got to be a passion there too. (Max)  Similarly, another participant explained that she sought information due to her innate interest in   89  caregiving, and desire to act in the best interests of the residents:  You have to just kind of see what’s going on and try to figure out how to make it better for them so they don’t escalate. I mean that’s the key, keeping everybody happy and calm. (Jo)  So, do you think that is something you learned in school? Is that training you’ve had on the job or is that just- (Interviewer)  It’s innate. It’s innate… You get experience, absolutely. And you see other people, other care aides, do things that are like “Oh, that’s a good idea”. But I think sometimes it’s just caregivers are caregivers because they care, generally. It’s like being a mom. It comes second nature, right? When it’s my kid I take care of it. I will do anything to keep it safe. That’s my opinion. (Jo)  Jo’s innate sense of caring motivated her to complete assessments and follow-up on resident changes. She contrasted her approach to that of co-workers, who she felt were less engaged in caregiving: I’ve seen people that’ve worked there for like ten, fifteen years and they don’t chart, they don’t send an email. They’re just like “Oh that person’s not standing.” And then they leave their shift because they don’t do it, right? So that’s why I say I think it’s, some of it’s just, caring people get it done because they want the best for that person. And some people honestly are in it for the pay cheque. (Jo)  Active knowledge seeking was a way to ensure that the care aides were able to act in the best interests of the residents, and further enhanced their positive self-images as trained caregivers.  Many participants highlighted their efforts to provide quality care to the residents by accessing health and treatment information required to meet the needs of the residents. For example, Lesley describes her thought processes in relation to a resident’s report of pain: If resident is showing signs of pain and things like that. I’d want to know “Ok, you know, so does this resident have MS? Do they have, like, arthritis? Do they have-?” So lot of those things, like if residents say “Oh, my joints are sore today”, and you know in your head, “Ok, you’ve got arthritis. You know, maybe I can ask for a PRN, or something”. But, like, there’s things like that that are kind of out of your control, but maybe there is things that are happening right then and there, that are in your control to help fix. Like maybe pants are too tight or, you know, something with like other garments, shirts or something, resulting in pain behaviour. (Lesley)  Willow compared her more informed approach to that of her relatively uniformed co-worker: 90  There’s one team member in the day time who has worked with us for something like thirty-five years, as a care aide, so she’s very familiar with everything, and yet she has this struggle with this one male resident….and so I go in there and I assist her helping this gentleman, and she says, “Ok, you have to make sure he keeps his arms to himself and his legs to himself while I do his care because he will start to swing out and kick, and this and that”. But, I mean on evenings, or on days, I can help this gentleman myself and there’s nothing, like there’s no agitation or anything. And the only difference is that she wants to get it done quick and fast… and I go in there and I just explain everything, and I’m slow. And it may take me ten more minutes, but what’s ten minutes in the grand scheme of eight hours, right?…. You can do, like a quicker harder way, or you can do it the easier, nicer, longer way that you gets you to a better place. Instead of him being agitated and then having to sit in his room and you know, just kind of grunt for an hour, he’ll be happy by the end of it.  (Willow)   With time as an ever-present pressure, Willow explained that a lack of time was a barrier to providing quality care and Jo shared that she has adjusted to the reality that she is not always able to provide the level of care that she would like to, but continues to prioritize to the best of her ability.  Preparedness  Knowledge seeking was described as a way to prepare for caregiving and maximize time for the provision of quality care. If care aides felt that there was inadequate time to prepare during regular working hours, they would complete knowledge seeking activities during their personal time. For example, Jo emphasized that coming to work early to gather information was important to her job, and was a regular part of her routine: I always come to work 15 minutes early, so you check everything, right? And then you’re not like, overwhelmed. So, the other shift is there and you’re like “Sorry, that’s your bell, not mine. I’m going to check my emails”, kind of thing. So you can get organized for your day. It’s like any job, right? Come prepared. (Jo)  Being prepared allowed the participants to make appropriate and safe decisions about the care they were providing. Lesley prepared at the beginning of her shift: Generally, at the beginning of my shift, because I want to be consistent throughout my whole shift, and I don’t want to have safety issues. Because what’s going to happen is, you start your shift, for example, you’re going half way through and you’ve been, say, doing a stand-by transfer with a resident, and all of a sudden, you look at notes later on 91  that evening, when you should have looked earlier, and you’re going “Oh, this resident has suddenly been changed to a full lift”. And you’ve been wondering why this resident’s been having a hard time standing this afternoon. Certain things like that happen so often, right? (Lesley)  Willow on the other hand, stated that her personal commitment and work ethic included use of her personal time for knowledge seeking in preparation for work:  There can be barriers if you make them… If you think “I don’t have enough time on my shift, so I can’t work on the computer”. Well, come to work 10 minutes early if you care enough to, and look at it. It’s 10 minutes of your whole day, and it’s information that’s necessary to work with these, these residents. Because they’re, humans are very complex, and there’s a lot to ask, and we need to know as much as we can about them to do the proper care. (Willow)  So, to address the barrier of time in your day, you are actually using some of your own personal time to make it happen? (Interviewer)  Yeah. I’ve always been the type of person, I’m never late, ever…. And in some places I’m actually begging for more time. Because I just need that extra 20 minutes to finish my laundry or do this and that, right? So, I do show up a little bit early, but that’s my choice… That’s my choice, to take an extra few minutes of my personal time, and I’m there anyways. I might as well gain some knowledge for my day. (Willow)  Preparatory knowledge seeking allowed the care aides to manage time more efficiently during the day. Tegan explained the relationship between being unprepared and stress: I normally work down this one hallway, like I know just about everybody down that hallway... And recently I’ve been working on the other side of the hallway, and it’s like I feel totally out of my element. Because you know down here I don’t have to be checking the care plan every two seconds. And, I know everyone’s routine. I know what they eat, I know their diet texture, I know their liquids, I know everything. Whereas down there I have no idea so it’s constantly anxious, trying to stay on top of things. And it affects your time management, and how much time you have for each person because I’m slower to do someone’s care because I don’t know them as well…. It makes it a lot more rough. Obviously, you feel you’re very time crunched with everything. Because it takes you longer to do something that you’re not regularly doing. It stresses you out. You feel way more burnt out at the end of your shift. You have a lot less patience with people and their behaviours during your shift. (Tegan)  Several participants shared that inadequate preparatory knowledge seeking impacted their emotions. Having or obtaining accurate information was perceived positively impacting emotional preparedness for work, making it “Definitely calmer and more manageable” (Jo): 92  I’ve got to know who’s my shower. I have to know who’s up. I have to know what I’m going to do for that day. I’ve got to know, right? (Jo)  So that you can plan? (Interviewer)  Yeah. I’ve got to know; any floor I walk in on I have to know who the laser alarms are. I have to know who my falls risks are. I have to know who needs a walker, they’re going to fall in the dining room. Those things I have to know or else my day will go really bad if someone falls. (Jo)  Relden also agreed that lack of sufficient knowledge to feel prepared made her shift more difficult and more stressful: You have to get all this information before you start their care. Because if you’re not knowing what the resident’s diet and their ADL needs are, it’s difficult, right? It’s more stress on your behalf all day figuring it out. Ok, you know, “What’s this person eat? This and this and that”. But if you know it ahead at least you can prepare yourself before mealtime. Right? I don’t like to have a stressful day. (Relden)  Tegan stated that emotional preparedness was the reason why she felt the need to check her emails regularly throughout the day, even on her days off: If they’ve had a fall or a decline in status, that’s like something that I check for when I read my emails when I’m off… because I mean, you have to emotionally prepare yourself to go back to work. And so I like to know going in, that “Ok, so-and-so had a fall, they broke their hip, so now I have another lift on top of this”, so you know I can like emotionally and physically prepare myself to go into work…. Because I mean it’s obviously super tough. Being a care aide is not easy at all. So, like I mean, even when you think you’re working in a certain part of the building and you show up to work and you find out you’re somewhere that’s either like easier or harder it’s kind of like a, “Ah dang-it”. You have to emotionally prepare yourself to head in to a secure community or, like one that’s for dementia, than preparing to work somewhere super easy and the majority of your residents are independent. (Tegan)  By gathering information prior to care, participants demonstrated that preparedness is an important part of providing quality care and a necessary step to decreasing stress and promoting emotional wellness at work. What is Right?   The participants often referred to doing that which is “right” or “in the best interest” of the residents. Willow explained that it was important for her to be well-informed about her 93  residents, because it was her job, and because it was ethically correct to provide appropriate care to other people: I just try to do my job well. And it has made the difference, because I do care about certain things like, I’m not just there to sign in and sign out. I’m there to, I mean I’m dealing with humans. I have to care. I want to know what I’m doing. I have to be on top of it. And it feels good when you know what you’re doing and, when you’re making a positive difference it feels good for myself, so, it’s a win-win situation. (Willow)   Lesley explained that she felt responsible for getting to know newly admitted residents so that she was able to meet their needs: Residents I work with all the time, you kind of see their normals and then their not-so-normals, right? But if it’s a resident that, it’s kind of like a person you just kind of met off the street, you don’t know much about them, right? So, you want to know a little bit of this and that about this person, right? This particular individual, right? In order to meet their best needs and stuff, right? (Lesley)   Max described feeling obligated to be keenly observant about changes in residents’ conditions because residents’ families were counting on her, and this fact motivated her to meet their expectations: The regulars know their personalities. They know that something’s not right. And even on a day-to-day basis you pick-up, you’re like “Something’s going on with that person.” You know like, “There’s something not right. I can’t put my finger on it but there’s something going on, that I don’t know what’s happening… I’m very hands-on with my residents. I like to know, they’re my family basically, they’re an extension of my family. Because their family have put their trust in me to look after these guys while they’re busy doing their lives… So, I’ve got to keep my eyes and ears open for everything [laughing]. (Max)   All participants valued being kind to the residents. Several shared stories about times when they had observed a resident who was upset which motivated them to seek information in order to ease that person’s distress. For example, Lesley described a time when her words had upset one resident, and she was reminded of the importance of knowing each person: …last year with a resident, I didn’t realize the words that I’d said until later when she’d actually mentioned it to me. Her call bell went off and I was with a resident at the time, but I left my resident to go in, make sure this women’s safe, and I said “Ok, well I’ll be back very shortly. I’m just with another resident right now finishing up”. So, you know, finished up, went back later and she said “Oh, when you were here and you said that it 94  kind of made me feel like I was just ‘a resident’”. And I’m like “Oh my gosh”. I didn’t really actually stop until after and go “Oh, that’s what my words could’ve actually been perceived as?” And that made me feel really bad, right? Because I’m thinking “This resident is more than just ‘a resident’”, right? But it’s just how it made her feel. Like she’s just this small [gesturing an inch]. It just made me feel super awful, right? Because I’m like “My gosh, I’m such a bad person”. It’s a learning experience, right? (Lesley)   The desire to be kind was a common thread throughout the participant narratives. Resident distress triggered knowledge seeking with the aim of comforting such residents. In her story about comforting a resident in emotional distress, Max highlighted her motivation to do what was right and ease suffering. Max stated that a distressed resident was her immediate priority and all other tasks were put on hold: If that means me sitting, if that means me not making a bed or getting laundry done, I’m sitting with that resident to comfort her, or him, and make sure they’re ok. Because their wellbeing is, to me, more important than making a bed or getting laundry done. That can be done at any point in time. For me, if that person is bawling their eyes out because they remembered a memory or they remembered that their husband passed away, or wife, and they’re just sitting there in their room, I’m going to sit with them. I’m going to hold their hand. I’m going to try and bring out happier memories as well. I’m going to. And that’s with all getting used to the resident. Finding out what they’ve told me about their husband or wife, and bringing that back on them. You know? Remembering “Oh, you used to own a store and you used to do this,” and then they start remembering the happier times and not the grieving death part of what has just happened. (Max)   Many of the participants described examining situations from the perspectives of others; for example, seeing themselves as residents, or family members of residents, or imagining their own family members as residents. They acted in accordance with what they felt they would want their caregivers to do. One participant illustrated this reflective process when she described caring for a resident who was unable to communicate verbally: When you do the care sometimes you, well I like to talk to them, even if they’re not listening to me, right? Even if they can’t respond to me, I’m still going to talk to you. You know? Because if that was my mother… If that was me, and that’s my mother laying in there, and she can’t speak, and somebody’s touching her without saying anything [shaking head]. I’m sorry, that’s their personal bubble. (Relden)  95  Lesley’s personal reflections about her own needs and wishes led her to be more mindful of her actions and interactions with residents: Every single day I think “Ok, if someone said this to me, how would I perceive this? What would I want?” Same with like, personal care. There’s just some things like, especially cross contaminants, stuff like that, you see out in the real world. Like I think “Gosh, how can a person come near me without washing their hands or changing their gloves?” I’m that kind of person through, right? And I know that I will be fifty years from now. And just giving variety and options, you know? “What would you like to wear today?” Not “Oh, this is what I would like you to wear. This is what I think looks great on you”. No, “What would you like?” Providing that preference, right? Sometimes that’s all we have left… something I like to see too is engaging in conversations. I do every night with each one of my residents. Every night, throughout care, because I may be the only conversation they have that day, right? So those are things I want. I’m a talker. And then later in life I will be, so I sure hope I’ve got someone looking after me that likes to chat. But also just provides me with the preferences and dignity... (Lesley)  Self-reflection extended into areas of practice beyond direct resident care. For example, although it was possible to access some information remotely, Lesley was quick to clarify that she valued confidentiality and that confidentiality of resident information was in keeping with the employer’s expectations of her as an ethical employee. Summary of Why I Seek Participant motivations for knowledge seeking often went beyond a deficit of information. Theme five contains three sub-themes. In the first subtheme, Natural Caregivers, care aides described knowledge seeking as an innate tendency for caregiving. The participants described being personally drawn to caregiving, and reasoned that a natural inclination for caregiving drove them to seek information that they felt was required to provide optimal care to residents. Participants explained how they felt passionate about knowing their residents, and being actively engaged in knowledge seeking to fill any gaps that prevented them from easing resident distress.  In the second sub-theme, Preparedness, participants explained that knowledge seeking was necessary to feel emotionally prepared to provide quality care. Quality care was considered by all of the participants to be a primary goal. At times care aides were motivated to seek 96  information in order to determine how they might most effectively manage the distress of their residents and achieve success in having care accepted by the residents. Knowledge seeking was also deemed to be an integral step to preparing oneself for work. This concept applied to both the provision of quality care and participants’ own emotional preparedness to manage the competing responsibilities and stresses that were commonly experienced during their shifts. Finally, in the sub-theme, What is Right?, participants described knowledge seeking from a moral and ethical standpoint. Participants expressed wanting to provide care for their residents that they felt was safe and ethically sound. Many participants described needing to assess each situation according to its own specific merits, and using knowledge seeking as a method to evaluate whether an action was appropriate. One of the specific methods that the care aides used to make these determinations was self-reflection. Self-reflection allowed the care aides to assess options based on what they felt they would want in a similar situation.  97  CHAPTER 5: DISCUSSION  I begin this chapter with a discussion of the findings in comparison to the literature. The concept of familiarity, as well as the theory of Figuring it Out in the Moment, are both clearly reflected in the participants’ stories, and each of the five main themes is reflected in the body of literature. I then explore the concept of Reporting as Knowledge Seeking, in which care aides used reporting as a method for gathering information. Next I discuss the practical implications of this research for workplace practice, training and policy, and make recommendations for future studies. Lastly, I outline the limitations of this study and present a conclusion. Familiarity  One of the overarching concepts noted in the participant narratives was familiarity. Knowing one’s residents, including both their care requirements and personhood, was valued by participants. Care aides explained that familiarity with residents was an important part of providing quality care, as it allowed them to tailor their approaches to the specific needs and preferences of each person. This finding is consistent with previous authors, who also confirmed that care aides valued “knowing” their residents, and considered it to be an important part of their jobs (Caspar, 2014; Rasin & Kautz, 2007; Mantzorou & Mastrogiannis, 2011; Tingström, Milberg, & Sund-Levander, 2010). The participants shared that having knowledge of each resident’s typical presentation, or “normal”, was necessary in order for them to recognize changes from that baseline. Changes in behaviour and conditions could not readily be detected if one was unfamiliar with how the residents presented on a typical day. This finding is also supported by Tingström and colleagues (2010), who noted that familiarity with residents’ normal behaviours allowed care aides to identify early changes compared to their baselines related to urinary tract infections. Multifaceted familiarity with the residents has been previously described by both research participants and investigators as something that is developed slowly over time through 98  interactions between the residents and their care aides (Caspar, 2014; Rasin & Kautz, 2007; Mantzorou & Mastrogiannis, 2011; Tingström, Milberg, & Sund-Levander, 2010). Many of the participants in this study emphasized that a benefit of working regularly on one unit, as opposed to being casually employed, was being familiar with the residents. In addition to improving their abilities to recognize changes, care aides explained that familiarity improved rapport, time efficiency and management of behaviours. Figuring it Out  In their theory, Figuring it Out in the Moment, Janes and associates (2012) described a four step process in which care aides make decisions about practice. Janes and colleagues (2012) surmised that care aides were often required to make decisions on an urgent basis, leaving little time for knowledge seeking in the initial phases of this process. Similarly, the participants in this study identified that they frequently felt pressured to “fix” a situation, or to “figure it out” on their own. When asked if there were any specific processes or tools in place to help with decision making, one participant answered simply: No. It’s kind of just basically up to me to figure it out, on my own. (Tegan) In addition to perceiving little support for information gathering, the participants often stated that there was not enough time for knowledge seeking and described feeling a sense of urgency in their work. Jo explained that she was constantly under time pressure to make decisions and complete her work:  You know what, it’s not an easy job and we just all have to figure it out, what we’re doing, to make everything ok…. you try to work with what you’ve got and fix it in the moment, right?(Jo)  Fixing it in the moment was stressful for Jo, as she explained that it was part of her job duties to fix whatever may be of concern to her residents: So it’s all about fixing and tweaking and fixing and tweaking and you just kind of, keep 99  doing that. (Jo)  When faced with uncertainty, rather than using algorithmic knowledge seeking patterns, the participants in this study engaged in knowledge seeking through trial and error. For example, Willow described how she learned from her own unsuccessful attempts to provide care for a particularly challenging resident, continuously working to improve her practice over time: When I first met him, I would just help him in a regular way that I help everybody and be like “Ok. Uh ‘ding’, that’s not going to work. That’s going to agitate him.” So I had to go back, “Ok, how can I do this better? How can I do this more suitable for this particular resident?” So it’s all about trial and error. “What works for him? What works for you? What works for the whole floor?” …. you have to be versatile with people. You have to see what works and what doesn’t work. (Willow)   Participant narratives reflected the theory, Figuring it Out in the Moment (Janes et al., 2012), as a current element of their knowledge seeking practices. The ability to figure out and to fix problems as they were occurring was a skill valued by the participants, and was considered to be an integral part of caregiving. Preferred Sources  Previous investigators have suggested that care aides prefer informal sources of information, such as verbal conversations, over formal sources such as digital and hard copy documentation. For example, Kontos and colleagues (2010) argued that supervising staff members believed that care aides used an internal auditing system for decision making, as opposed to formal care plan documents. A preference for informal sources of information, however, was not shared by the participants in this study, many of whom described using care plans, ADL sheets, and progress notes regularly to learn about the residents. Lesley stated that she regularly accessed care plans, estimating that she read them “at least once” every shift. This finding was supported by Willow, who, when asked how frequently she accessed care plan documents, said “We’re always going through there”.  100   One deterrent to using care plans and other formal documentation that was evident in this study and in previous studies was uncertainty about the accuracy of the information. For example, a participant who was employed casually as a care aide described how she usually needed to double-check information with regular staff members because “Care plans aren’t updated, on a regular basis” (Tegan). Similar findings were noted by Caspar (2014) who suggested that if care aides felt that the information was not up to date they were much less likely to review it, and to use it to guide their care giving.   Kolanowski and colleagues (2015) as well as  Rasin and Kautz (2007) explained that care aides are unlikely to use care plans if they do not feel involved in the process of developing the care plans. The majority of the participants in this study clearly stated that they were involved in care planning and creating the bedside documents, or ADL sheets. For example, Willow described how she and her teammates were involved in updating the ADL sheets: If myself or regular care staff notice that they aren’t up to date, we just take them off the clip board in their room, bring them to the kitchen and then we can reassess them and update them. We’ll leave them on the counter. There’s days, evenings and nights. And so regular care staff on days, evenings and nights will have to fill out their portion of the [ADL Sheet]. There’s three different sections. (Willow)   Likewise, Max stated:  If their mobility has changed, if they’ve lost weight, if their bowels are regular. From A-Z we look after it. (Max) Although the participants did express a preference for formal documentation as long as the accuracy of the information could be confirmed, they suggested that they also needed to validate their findings with their co-workers. For example, a participant discussed investigating a concern about one of her residents by contacting her co-worker to determine if the co-worker had also noticed a change. When Max stated that “My red flags are starting to pop up”, it was important for her to verify her observations with someone else because “I need that back up” 101  (Max). Their tendencies to validate information and observations with co-workers is similar to “affirmational support,” described by Estabrooks and colleagues (2005). Estabrooks and associates (2005) explained that nurses rely on verbal conversations with other nurses as an emotional outlet and way of gathering support for things they already believed to be true.  Multiple authors have previously indicated that training programs, in classroom settings or online, have a positive impact on care aide performance (Kemeny et al., 2006; Wilson, et al., 2011).  In this study, however, care aides expressed mixed opinions of the usefulness of their formal training programs and subsequent courses. Although some of the care aides stated that they used processes learned during their care aide training programs to assess their residents on a regular basis, most participants said that their formal training was of little use to them as they needed to tailor their approach to individual residents and situations. Most participants explained that experience over time was their preferred method of knowledge advancement and most perceived that the art of caregiving was more valuable than formal training. For example, they were more likely to incorporate information gained through personal experiences combined with observations of the residents in the moment, similar to the findings of previous authors (Kontos, Miller, Mitchell, & Cott, 2010; Rasin & Kautz, 2007). The care aides in this study also described feeling motivated to ask ethical questions about “What is right?” and reflect on their personal value systems which is similar to the findings of Kontos and colleagues, (2010) and Tuckett (2012).  Finally, while Furåker and Nillson (2009) found that care aides reported little interest in acquiring formal knowledge about dementia, three of the eight participants in this study described seeking online information outside of work hours as a way to manage specific resident concerns and prepare themselves for their work.   102  Not Enough Time The findings regarding time pressures in the present study are well supported in the literature. Several authors have also reported that insufficient time to complete duties is a pervasive factor in care aide work and knowledge seeking (Caspar & O’Rourke, 2008; Knopp-Sihota, Niehaus, Squires, Norton, & Estabrooks, 2015; Kontos et al., 2009). In most instances, the amount of time available for resident care is directly related to the care aide-to-resident staffing levels, with greater numbers of staff resulting in more time for each resident. In 2009, the British Columbia Ministry of Health set the minimum staffing levels for residential care facilities as 3.36 hours of direct care per resident per day (British Columbia Ministry of Health, 2017). Despite this benchmark, recent internal and independent reviews found that up to 81% of residential care facilities in the province operate below this minimum staffing level (British Columbia Ministry of Health, 2017).  The partcipants in this study all indicated that providing quality care was very important to them, and that a lack of time was a barrier to this care. This finding is consistent with the conclusion of Estabrooks and colleagues (2015) that care aides have a remarkably high sense of meaning and value in their work. This sense of job-worth, when challenged by an inability to do the best possible work due to time barriers, can create significant morale distress for care aides. Burn-out and poor retention of care aides related to stress and distress may further compound the impacts of inadequate staffing levels and available time.  Reporting as Knowledge Seeking Throughout the interviews the care aides shared stories about communicating with their teammates, including nursing staff. They routinely reported changes in the residents to their supervising nurses, as is common within the hierarchies of most residential care facilities. In this study, however, I found that for some care aides, the intention to report was dualistic: to pass on 103  information but also to seek knowledge about a resident, treatments or next steps. In this section I review the standard hierarchy in residential care facilities and the power and reporting structures described by participants. I include interview extracts that illustrate the concept of reporting for the purpose of knowledge seeking. Assigning and Delegating In British Columbia, both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) have professional practice documents that guide the processes by which care can be passed from nurses to care aides (College of Registered Nurses of British Columbia, 2013). The two processes involved in the distribution of tasks are “assigning” and “delegating”. Assigning a task occurs when a task that would normally be the duty of a professional nurse is passed to a care aide. The task must be within the assigning nurse’s scope and individual competence, and must be permissible within the job duties of the care aide as set out by the employer (College of Registered Nurses of British Columbia, 2013). The professional nurse retains the responsibility for resident assessment, care planning and evaluation, as well as evaluation of the care aide’s training and competence in completing the task. Both LPNs and RNs are permitted to assign tasks to care aides (College of Licenced Practical Nurses of British Columbia, 2014; College of Registered Nurses of British Columbia, 2013). Delegating tasks, however, is an RN function only. Delegation of tasks occurs when the responsibility of providing an intervention that would normally be a duty of the nurse is passed to the care aide. A delegated task is not included in care aide job duties as set out by their employers. Delegation should only occur after careful consideration of the best interests of the resident, and should be resident-specific (College of Registered Nurses of British Columbia, 2013). Delegation requires a greater level of responsibility from the RN when assessing each care aide’s competence, and the provision of resident-specific training in the intervention. Typically, tasks are not delegated in residential care 104  facility environments, but task assignment by both RNs and LPNs is a regular occurrence. It should be noted that there are significant differences in the education and training of the two professional nurse designations and in some residential care facilities there may be no RN to support and collaborate with LPNs who are supervising and assigning tasks to care aides.   Reporting and Power Structures Power dynamics that impact knowledge seeking are evident in existing literature and were also evident in my data. I asked the participants about the other disciplines they routinely reported to, and which of their co-workers reported to them. I used these data, in combination with descriptions given by the participants during the interviews, to produce visual interpretations of the two reporting structures on the units. The participants indicated that one or both of the structures were in place at their worksites. Figure 2 represents the traditional reporting structure within a residential care facility. The care aides report to the LPN or RN and management, and receive reports from other care aides. In some situations, care aides also receive reports from casual staff members, paid companions of the residents, and volunteers. This structure emphasizes the hierarchy impacting the flow of information between different disciplines within the team. Seven participants indicated that this type of reporting structure was present in their worksites, with four care aides identifying that this was the only reporting structure in place.  Figure 3, on the other hand, represents an alternate, contemporary reporting structure within a residential care facility. Half of the participants indicated that this type of structure was present in their workplace at least some of the time and one participant stated that this was the only reporting structure in place. The care aides report to, and receive reports from, all of the members of the team. Likewise, the team members both report to, and receive reports from, the care aides. The reciprocal nature of this reporting structure emphasizes open communication 105  between all staff members regardless of discipline or role. A collaborative philosophy and shared power are valued in this environment.          Figure 2  Traditional Reporting Structure    106     Figure 3   Alternative (Contemporary) Reporting Structure   107  According to previous research, when a traditional reporting structure is in effect, some care aides feel distressed by their lack of power to make care decisions in the best interests of residents (Kontos et al., 2010). The participants in this study described many occasions during which their voices were silenced or not acknowledged by colleagues in positions of power.  Participants expressed frustration and moral distress, similar to that depicted by Kontos and associates. (2010). While some authors have suggested that access to information is a source of power in the workplace (Caspar, 2014; Caspar & O’Rourke, 2008; Chaudhuri, Yeatts & Cready, 2013; Kolanowski et al., 2015; Kontos et al., 2009; Rasin & Kautz, 2007), most participants in this study stated that they did not believe that power was a factor in accuracy of information or that it blocked them from seeking and/or receiving relevant information. Instead, they attributed gaps in knowledge to ongoing changes combined with unintentional miscommunication: We’re not being blocked. We’re not being misled on purpose. (Jo) Giving Report  Reporting changes to nurses or other co-workers is an important component of the care aide role, and is considered an essential part of team communication. For some care aides, reporting was a way to share information, but reporting was also an element of knowledge seeking; a person who is sharing information is a source for the next person who is seeking knowledge:  I will chart on how my shift was with them, they can read it, the next person can read what’s going on, and then we can kind of gauge it and get lots of information. (Jo) Reporting was the first step in preparing for knowledge seeking and useful to trigger knowledge seeking in others: [I will] usually report it to the nurse, and then I still want to, like if I can, I still want to look at that information so I’m learning from it, but also so the nurse is aware, you know, this is occurring. (Lesley)  108  Lesley responded to a change in a resident’s condition by noting the change, and then reporting the change with the intention of triggering further assessment that would provide her with new knowledge: Especially with swallowing, you know, if it’s saying they’re nectar thick, or they’re, you know, minced or whatever, and I’m going “Gee this person is looking like they are having a pretty hard time trying to break down their food, not able to swallow it, you know? Showing signs of difficulties of swallowing”. That’s when I’d stop and go “Ok, need a little more about this resident. Ok, they are nectar, they are this? They are that? Ok.” And then that’s when I want to document it and then also report to the nurse and hopefully have an assessment. Have that resident reassessed for their textures. (Lesley) Similarly, Ross described her intentions of gaining new knowledge by reporting information that would trigger further assessments: Well, I think it would depend on what it is. Like, if it is a fall, then we need to figure out why they fell. Did they trip on something? Did they trip on a crash mat? Are we not getting to them on time? Are they weak in the morning? Are they weak in the afternoon?... if it’s an open sore, we report that. Creams, whatever, that will be ordered. (Ross) So, to see what treatments are needed or what the next steps would be? (Interviewer) What the steps would be, yeah. (Ross) To start that investigation process to figure out what to do next? (Interviewer) Yeah. (Ross)  Unfortunately, some participants viewed their roles simply as observers and reporters, rather than as active knowledge seekers. For example, when Max spoke about her experience with a resident whose appetite had decreased, she placed a strong emphasis on role of care aides as observers, and their duty to communicate changes: Also communicating if the person isn’t eating, because that’s another sign of something happening. The person who was eating, all of a sudden their appetite’s not there anymore. They’re barely eating, they’re barely drinking. It’s very important to communicate that, because that could be a red flag for something that is an underlying issue. So yeah, every little aspect, even down to their p- [laughing] poo and peep you know, you have to know what’s going on because you’re so on the ground zero of everything. You know that “Ok this is not normal”, like “Why is this happening?” (Max) 109  Being on “ground zero” seemed to be an integral part of care aide identity. While most of the participants felt that it was their responsibility to notice and report any changes, the care aides who focused most on the observer and reporter roles failed to see themselves as knowledge seekers. Most often, they described reporting changes to nurses or other staff members in positions of authority, and then expected that person to move forward with knowledge seeking. For example, Relden explained that she reported changes and then waited for the LPN or RN to take action: The first thing I would do, I would tell my LPN. I would put it in the progress notes. And then, whatever that goes from there. Either the LPN or the RN or our manager would go from there. (Relden)  In the traditional reporting and power structure (Figure 2), information moves up the hierarchy, from the care aides to nurses and upward. Presumably, the power to act on observations and make care-related decisions is also linked to this hierarchy, and so participants may have initiated reporting, as opposed to knowledge seeking, due to the perception that they did not have the power to create change. In the contemporary reporting and power structure (Figure 3), the flow of information passes back and forth between team members regardless of their job roles. While the contemporary structure emphasizes a collaborative approach, it is unlikely that care aides are independent decision makers. The power structure for decision making, therefore, remains fairly consistent and may reinforce the perception of the care aide role as observer and reporter rather than active knowledge seeker.  Practice Implications In this study, the knowledge seeking patterns of care aides within the context of employment at residential care facilities were examined. The practical implications which can be drawn from this research are diverse, and applicable to workplace practice, training and policy. As previously discussed, time remains a pervasive barrier to knowledge seeking. While current 110  staffing levels in British Columbia present significant strains on available time, it is not impossible for creative managers to make changes that enhance knowledge seeking among care aides. Workplace Practice  The first recommendation for workplace practice is that care aides should be engaged as valued team members in the creation of care plans so that they feel part ownership for maintaining these important formal documents. Once care aides are involved in care planning and document creation, they should continue to review care plans and ADL sheets on a regular basis, even for residents whom they know well. Some care aides with permanent rotations could become complacent about checking for updates, if they feel they are already familiar with the residents, therefore these care aides may not be aware of recent changes. A shift towards regularly scheduled knowledge seeking practices needs to be encouraged and supported by employers and supervisors, until it becomes ingrained in the care aides’ daily routines.  Care aides often validate the information they find though conversations with co-workers.  Therefore, the second recommendation is that employers should consider investing in technologies such as voice transmitters, voice memos, or speech-to-text computer software that permits care aides to communicate verbally with co-workers, even when they cannot meet face-to-face. These technologies honour care aide preferences for verbal communication and can help facilitate knowledge seeking activities during busy shifts.  Training  The next recommendations are related to training programs. Administrators and directors of care aide training programs should be aware of care aide knowledge seeking patterns and use the awareness of these patterns to inform their curricula. Unless adequate improvements have been made to staffing levels, training should occur outside of regular shifts. Care aides should not 111  be required to attend training or complete training modules at times when they are responsible for resident care, as the morale distress and stress related to time constraints is already a significant concern.  As technology continues to be incorporated into the daily work of care aides, it is important that care aides feel competent using these tools. Administrators and directors of care aide training programs should make the effort to include regular computer-based activities in their curricula, and should consider offering elective courses for individuals who require additional support to develop technological competence. Skills such as typing, creating and editing files, data entry into fillable forms, and internet navigation are all commonly required for care aide work, and efficiency in these tasks saves time.   Given a preference for verbal knowledge seeking, effective communication skills should be practiced by care aides and their co-workers, including those in positions of authority. Employers can support effective communication by offering coaching or training sessions in interpersonal communication and fostering healthy working relationships. Emphasizing the essential roles of care aides in observing and communicating changes, as well as contributing to knowledge seeking, may help to enhance teamwork and information sharing. Instructors who train care aides should emphasize the importance of keeping abreast of changing care needs, and avoid the assumption that resident conditions are static. Care aides should be taught how to prioritize knowledge seeking activities even though they have many other competing tasks in their workloads. It is also important for instructors to encourage care aides to ask questions or voice concerns and nurture care aides to develop a self-identity that includes the role of knowledge seeker. Care aides should be taught that they are crucial links in gathering and communicating information about residents, and must feel empowered to address gaps in knowledge or care. If care aides are taught to envision themselves as knowledge seekers 112  or investigators, as opposed to simply observers and reporters, they will engage in knowledge seeking activities when at work and the care for residents will be improved.  In turn, care aide knowledge seeking, if valued and self-identified, translates into care aides being viewed by others as knowledge holders. This will increase the probability of other staff accessing the care aides as important sources of knowledge, further establishing the position of care aides as valuable contributors to knowledge seeking and knowledge sharing.  Policy There are also implications for policy arising from this study. For the purposes of this document, the term “policy” means a plan, rule or regulation that is intended to influence and determine decisions or actions. Residential care administrators and managers should review shift routines and ensure that adequate time is allotted specifically for knowledge seeking. The care aides in this study clearly articulated that they want to give high quality care and that in order to do so they need to be able to access accurate and up-to-date information on a regular basis. The participants spoke about “always” or frequently spending personal time for information seeking. Residential care managers should consider allocating a specific time during the day for care aides to review documentation and to pass on verbal and written information to their co-workers. Reduced workload or additional staffing may be required to create this extra time without negatively impacting the time available for resident care. The location of information storage should also be taken into consideration, to facilitate access to knowledge via sources close to where hands-on work is occurring. It is also important that employers recognize the role of familiarity in knowledge seeking. Formulating staffing matrices to maximize the frequency that a given care aide works with a specific resident fosters familiarity, which in turn enhances the likelihood that subtle changes in the resident’s condition or behaviour will be noted. This also minimizes the amount of time 113  required to gather information each shift. When care aides are familiar with their residents they can focus on knowledge seeking related to changes, rather than knowledge seeking to collect general information on each resident they will care for that day. To address gaps in knowledge at the time of resident admissions, employers should review their processes for knowledge transfer and knowledge translation. Up-to-date information should be collected prior to the admission and transferred to the residential care facility staff in a timely manner. Ideally, acute care and residential care services should work together to develop protocols for admissions that meet the information needs of all parties, and provide the best possible transitions for residents. Policy makers should acknowledge the power imbalances between care aides and other staff, and work to reduce these as much as possible. Establishing clear expectations for respectful interactions and teamwork should be mandated, as well as ongoing monitoring of potential instances of neglect, intentional miscommunication or bullying by co-workers. Awareness campaigns regarding the important role of care aides as both observers and knowledge seekers should be undertaken. I recommend messaging that positions care aides as essential members of the team who make valuable contributions to care planning. Their familiarity with the residents and “ground zero” perspective, make care aides an excellent source of information. When power relationships are optimal, care aide preference for verbal communication creates mutually beneficial opportunities for engagement with other staff members for “just in time” knowledge seeking, beyond what would be possible with other knowledge sources, such as ADL sheets or email communications.  Implications for Future Research  Although I have attempted to offer meaningful accounts of the knowledge seeking patterns of care aides, as they described them, and provide strong evidence for my conclusions, 114  my findings are contextually limited. All participants worked at one of three faith-based privately owned residential care facilities located in an urban setting. The knowledge seeking patterns of care aides who work in publicly owned residential care facilities could be different. In future studies, a larger sample with care aides of more diverse characteristics is recommended. For example, there is an urgent need to discover the perspectives and knowledge seeking activities of care aides who are not fluent in English. Similarly, a study that includes care aides of different genders and generations, and in rural settings is recommended. A study with targeted recruitment of care aides from day, evening and night shifts, as well as a range of unit types should be also be undertaken.   Observations of participants while at work were not part of the data collection methods for this study, but are recommended to expand on the self-reported knowledge seeking activities of care aides. For example, observations could include the collection of numerical data regarding frequency of use for different knowledge sources, time spent in knowledge seeking activities, and timing of knowledge seeking activities. This quantitative data could be used to confirm the qualitative findings and provide another source of evidence for policy makers.  Future research might be focussed on outcomes of different methods for enhancing knowledge seeking, using interventions at different points on a continuum from pre-employment to the seasoned worker. Comparing outcomes of various curricula on knowledge seeking activities would be valuable for program administrators, directors and policy makers. Both pre-employment training and post-employment training should be included, as well as new curricula developed by researchers. The findings from these types of studies may result in improved understanding of which types of training interventions improve knowledge seeking.  In future, researchers may also wish to examine the implications of different information sharing methods, and how these methods impact knowledge seeking and dissemination of information.  115   Researchers may wish to compare different methods of verbal communication, use of technology and documentation in terms of the efficacy of information sharing. The impact of tools such as checklists, communication books and ADL sheets could be compared for ease of use, speed of communication, accuracy of information and care aide preference. In addition, new tools developed by the researchers could be trialed, and assessed in terms of frequency of use and user satisfaction, care aide morale or productivity. The findings of these studies could further specify which methods of communication should be recommended for workplace practice and quality care for residents.  The participants in this study voiced some concerns about the availability and accuracy of information, as it is passed from one person, or group, to the next. A study of the impact of knowledge sharing and the resulting accuracy and quality of the information, as it is received by care aides, should be undertaken. The participants also varied in their opinions of the accuracy of care plans or ADL sheets, so researchers in the future could audit documents in use at residential care facilities, compare them to what is known about the residents, and report accuracy and accessibility of the information available to care aides. Knowledge sharing and ease of access to information might also be compared to resident satisfaction and quality of life scales, or to quality of care indicators including behaviours, falls and other accidents or errors. Finally, methods of knowledge seeking and knowledge sharing could be compared using tools designed to measure worker satisfaction, injuries, attendance, recruitment and retention. This would enable employers to make informed decisions about staffing strategies and worker safety. Limitations  In this analysis my intent was to capture the essence of knowledge seeking as it was related to me by the participants. There are some important limitations that should be acknowledged. This analysis is my interpretation of the stories that I heard, and does not 116  necessarily represent the themes that would be extracted from data collected from a different cohort of care aides, nor themes that would be identified by a different researcher. The immersive nature of qualitative research makes it impossible for my personal biases and worldview to be completely separated from this work. With over a decade of experience working in residential care facilities, I have an intimate understanding of the research area and have developed personal opinions and values over time. Despite the structured efforts to maintain rigour and reflexivity, as previously described, my personal biases may have affected how the findings were generated, both during the interviews and the data analysis.    The participants in this study varied in age, ethnicity, first language and employment experience, however, all of the care aides were under fifty years of age and there was no variability in reported gender.  The average age of the participants (35.75 years) was lower than the average age of care aides in British Columbia, which is 45 years (Health Employers Association of British Columbia, 2014). WorkBC (2018) estimates that in 2015, 23% of healthcare employees were 55 years old or more, while the oldest care aide in this study was 47 years old. It is possible that older care aides, and those closer to retirement, may have differing perspectives and habits related to knowledge seeking. While the prevalence of female participants is consistent with the workforce in British Columbia, where up to 81% of people employed in healthcare in 2015 were women (WorkBC, 2018), male and alternatively gendered care aides may not share the ideas of the female participants presented here. In particular, self-identity, and therefore role-identity, may differ in non-female care aides and lead to alternative knowledge seeking patterns.   All of the participants were trained in British Columbia, taking programs approximately six months in length. They all worked for the same employer in facilities within a small geographical area of urban/suburban neighbourhoods. The consistency in their training and 117  employment experiences may have impacted the ways in which the participants established their patterns of knowledge seeking and will likely account for some of the similarities in their perceptions and descriptions of knowledge seeking. The urban setting and substantial size of the facilities may have also influenced the knowledge seeking patterns of the participants. Care aides working in smaller facilities or in rural settings may have developed different knowledge seeking patterns in their particular contexts.   The employer is a Christian-oriented company with direct ties to a major Canadian church organization. While the employer does not require that care aides self-identify as Christian or follow the Christian religion, their recruitment advertisements state that all care aide employees are expected to exemplify “Christ-like values” and demonstrate “Servant Leadership” when interacting with residents. A focus on religion-based values may have impacted participant thoughts and beliefs about knowledge seeking as they apply to caregiving. In particular, the ethical motivations for knowledge seeking such as questioning “What is right?” may have been directly influenced by the established expectations of acting in accordance with Christian values.   I employed one method, semi-structured interviews, to gather data from the participants. Some of the participants spoke about topics that were not directly related to the research questions. The self-reporting nature of the interviews presented a limitation in that my data collection was dependent on what information the participants chose to share, and how they chose to express themselves. It is possible that the participants crafted some of their responses to reflect what they thought I, as researcher and residential care nurse, would want to hear, or to demonstrate to me that they knew standard or expected practices. This limited the perspective from which I was able to view care aide knowledge seeking patterns.    118  Conclusion The purpose of this study was to explore the knowledge seeking patterns of care aides who provide care to residents in residential care facilities. I collected and analyzed data from semi-structured interviews with care aides and created a thematic map of the findings. It was not my intention for the findings to be generalizable to all care aides.  In this study, the holistic concept knowledge seeking patterns includes why knowledge is sought, when knowledge is sought, who knowledge is sought from, specific tangible sources of knowledge preferred, and preferred sites for knowledge. A preference for formal documentation, validation of information with co-workers via conversations, familiarity with residents, figuring things out as they go along, and use of reporting as knowledge seeking are the key concepts that define the patterns of knowledge seeking among the care aides in this study. I answered the secondary research questions by examining different aspects of the knowledge seeking patterns within each theme. Care aides seek information to provide high quality care, feel prepared and satisfy their personal assessments of ethics. They are most likely to seek information in response to resident changes or when there is a dearth of information, such as at the time of admission. At the start of, or before, a shift is the most common timing for information seeking, with the next most common being outside of working hours. Tangible knowledge sources that are convenient in location and specifically relevant to care aide work are preferred, as well as those that save time. Because of this, ADL sheets were considered the most useful care documents by the participants. Verbal communication, however, was the most preferred form of knowledge seeking overall. Collectively, I found that these themes provided a rich description of the knowledge seeking patterns of care aides in residential care facilities.    119  References Andersen, E., & Spiers, J. (2015). Alone in Eden: Care aides’ perceptions of consistent assignments. Western Journal of Nursing Research, 37(3) 394–410. Baby, M., Glue, P., & Carlyle, D. (2014). ‘Violence is not part of our job’: A thematic analysis of psychiatric mental health nurses’ experiences of patient assaults from a New Zealand perspective. Issues in Mental Health Nursing, 35(9), 647-655. Berta, W., Laporte, A., Deber, R., Baumann, A., & Gamble, B., (2013). 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Journal of Psychiatric and Mental Health Nursing, 19(1), 40–46.    131  APPENDICES   132  Appendix A: Search Terms and Results Database(s) Date Search Terms # of Results CINAHL and ERIC October 9, 2016 nurse AND knowledge source  65 nurse AND knowledge source  42 support worker AND decision  6 support worker AND communication   15 support worker AND information   17 support worker AND knowledge   12 support worker AND literacy   1 nurs* aide AND decision  2 nurs* aide AND communication   5 nurs* aide AND information   8 nurs* aide AND knowledge   3  nurs* aide AND literacy   0  nurs* assistant AND communication   0  nurs* assistant AND information   0  nurs* assistant AND knowledge   0  nurs* assistant AND literacy   0  nurs* assistant AND communication   0 care assistant AND decision   0 care assistant AND communication   0 care assistant AND information   7 care assistant AND knowledge   5 care assistant AND literacy   0 care worker AND literacy  1 care worker AND information   11 care worker AND knowledge   16  care worker AND decision   11  care worker AND communication   11  care attendant AND decision   0  care attendant AND communication   1 care attendant AND information   3 care attendant AND knowledge   3  care attendant AND literacy   0 healthcare attendant AND literacy   0  healthcare attendant AND communication   0 healthcare attendant AND information   0  healthcare attendant AND decision   0  healthcare attendant AND knowledge   0  healthcare aide AND communication   0 healthcare aide AND information   0  healthcare aide AND knowledge   1 healthcare aide AND literacy   0  healthcare aide AND decision   0 133  Database(s) Date Search Terms # of Results CINAHL and ERIC  October 9, 2016 care aide AND decision   0  care aide AND communication   1  care aide AND knowledge   1 care aide AND literacy   0  patient support assistant NOT teaching assistant   140  patient support assistant   184  unlicensed healthcare   0 unregulated healthcare   1  unregulated care*   1 unlicensed care*   4  unlicensed assistive personnel   4 assistant practitioner   4 associate practitioner   2  CINAHL Complete associate practitioner  5 assistant practitioner  72 care assistant AND decision  18 support worker AND decision   18  nurs* assistant AND decision   5 nurs* aide AND decision   5  care assistant AND decision   12 care worker AND decision   41  care attendant AND decision   4 healthcare attendant AND decision   0 healthcare aide AND decision   1  care aide AND decision   3 care assistant AND communication   16 care assistant AND information   24  care assistant AND knowledge   26  care assistant AND literacy   2  patient support assistant   1  unlicensed healthcare   1  unregulated healthcare   1  unregulated care*   11 unlicensed care*   10  unlicensed assistive personnel   17 October 8, 2016 care assistant AND decision  24 healthcare aide AND decision   1  care aide AND decision   3  healthcare attendant AND communication   1  healthcare attendant AND information   2  healthcare attendant AND knowledge   2 healthcare attendant AND literacy   0  care attendant AND communication   5  care attendant AND information   4 134  Database(s) Date Search Terms # of Results CINAHL Complete October 8, 2016 care attendant AND knowledge   6  care attendant AND literacy   2  unlicensed care*   18  unlicensed assistive personnel   27  support worker AND communication   65  support worker AND information   79  support worker AND knowledge   49 support worker AND literacy   2  support worker literacy   0 care worker AND communication   167 care worker AND information   209 care worker AND knowledge   258   care worker AND literacy   3  October 7, 2016 nurs* assistant AND communication  176 nurs* assistant AND information   178 nurs* assistant AND knowledge   229 nurs* assistant AND literacy   3 healthcare assistant AND communication   12 healthcare assistant AND information   23 healthcare assistant AND knowledge 24 healthcare assistant AND literacy   0 healthcare aide AND communication   2 healthcare aide AND information   3 healthcare aide AND knowledge   1 healthcare aide AND literacy   0  healthcare aide AND literacy   0 October 06, 2016 support worker AND communication  65  support worker AND knowledge  49  support worker AND information  79  support worker AND literacy  2  nurs* aide AND communication  19  nurs* aide AND knowledge  15  nurs* aide AND information  14  nurs* aide AND literacy  0  care aide AND information  6    135  Appendix B: Recruitment Handout      136  Appendix C: Recruitment Poster  137  Appendix D: Participant Demographics and Characteristics Collection Instrument  138     139  Appendix E: Information Letter and Consent Form  140   141   142         143  Appendix F: Transcriptionist Confidentiality Agreement   144  Appendix G: List of Pseudonyms      145  Appendix H- Guiding Questions      146  Appendix I: Notes from Phase 1 Data Immersion  audio recordings of all interviews have been listened to at least three times  five of eight interviews have been transcribed by the researcher  remaining three interviews transcribed by transcriptionist  interviews transcribed by transcriptionist then edited by researcher for accuracy  September 18-20, entire data set reviewed en masse, including transcripts, audio recordings, memos, and field notes Initial Thoughts:  the care aides covered a wide range of topics both relevant and irrelevant to the questions asked  some stories which initially appeared tangential may contain details that can be abstracted to give a better picture of the knowledge seeking patterns. Ie: the care aide may describe the official processes of knowledge seeking and one way, but then tell a personal story about a work event in which the knowledge seeking process was quite different  many of the responses to questions about knowledge seeking produced answers that were heavily focused on reporting rather than information seeking. Is this because the care aides see themselves more as the eyes and ears of the operation with a heavy focus on observation, rather than the self-image of being knowledge seekers or investigators such as one might expect from nurses. I am also wondering if the care aides felt that they needed to tell me, the researcher, that they know how to do their job properly and so described what they may have previously been told is the most important - reporting any concerns to the nursing staff for follow-up. This confusion may have distracted some from bringing to light the actual knowledge seeking behaviours  as the interviews progressed it became more clear that reporting is actually a part of knowledge seeking, as this reporting process may lead to conversations about a new or PRN medications as well as stimulate the in initiation of assessments by other health care professionals to find out what is going on with the resident  care aides also described reporting as a way of inquiring about changes - does the resident have a new condition, medication, treatment that the care aide was unaware of?  Who- other care aides were a primary source of information, this was seen as a benefit due to time, but also due to the specific lens of the care aide in which actual experience with a specific resident doing a specific task was viewed as highly valuable information. 147  Care aides to care aide relationships impacted both the availability and the perceived reliability of the information  Who- some of the care aides indicated residents themselves as being an important source of information, an interesting aspect of this was that the care aides who worked in the dementia units, whether as casual or regular staff, appeared to value observing the resident and getting to know them well enough to recognize changes in their facial expression in particular “the eyes”/possibly brows  Who- opinions on information coming from family members were widely varied. Some care aides believed that family members “sugar-coated” the truth while others catastrophized. Some care aides stated they rely heavily on family members information about particulars about a resident while others stated they do not use family members as an information source at all due to the family members not understanding dementia, and perhaps no longer knowing how to relate to the resident  Who- nurses and other healthcare professionals were also noted as a source of information to varying degrees. Some interpersonal relationship issues between staff members were noted as barriers to this information source  What- tangible knowledge sources mentioned included the charts, the care plans, ADL sheets, social history documents, electronically charted progress notes, cheat sheets/shift guidelines  Kinds of information- care aides wanted to know information about safety concerns such as dietary restrictions, mobility plans, falls risk and aggression. However, the greatest emphasis was on learning about the residents particular needs at that point in time, i.e. their preferences, their care routines, and any tips and tricks that will help the day go smoother (time and resident distress were noted as factors)  when- most of the care aides indicated the onset of shift as being the best time to collect formal information, once the shift was in full swing they often found it difficult to get back to the computers and the charts, although there was some mention of accessing ADL sheets and other quick documents while on the move  when- all but one of the care aides indicated doing some form of knowledge seeking outside of regular work hours. This varied from coming a few minutes early to shift to check emails, to spending time at home researching specific health related topics and target times for care tasks, as well as texting with other care aides about specific resident changes. Several of the care aides made comments about needing to be prepared mentally and emotionally to come to work, and that there was a negative impact when there were last-minute changes, in particular the casuals who would come thinking they were on one unit and end up needing to work on another  when- there were very few instances that care aides indicated would be “show stoppers” that would cause them to pause in the moment and move no further before 148  seeking more information. Rather they were more likely to continue on with their tasks, potentially switching to a “downgraded” safer version of a fluid or transfer, and seeking more information “when I have time”  where- most of the formal sources indicated were located in central areas such as the kitchen, nursing station, or hallway. ADL sheets are located in the bedrooms to be accessed during care  what- none of the care aides expressed difficulty accessing information on the computer, although some indicated that others might have trouble with this. Only one person indicated having difficulty deciphering information on the chart  why- the care aides indicated three main motivations for knowledge seeking: providing excellent and appropriate care that focused on safety and honouring the resident, viewing the resident as an extension of their family or comparing them to “what would I do if this was my family/what would I want for my family member”, and also to “cover my butt”. “Cover my butt” was more heavily focused on reporting, but did also include double checking verbal reports and any inconsistencies between documentation sources, or documentation and verbal sources  many of the care aides indicated that trial and error or “figuring it out” on their own was a regular knowledge seeking process on their shift. This appears to be related to the unpredictability of the work as residents do not remain consistent through time, from one activity to the next, or with one person or the next  the most common trigger mentioned to alert the care aides that knowledge seeking was a due, with changes in a resident’s behaviour - increased agitation, the appearance of distress, a change in a way that they interact with the care aides- many care aides indicated that a deep and personal understanding of each resident is required for quality care. This personal understanding allow the care aides to see small changes and recognize that there was some trouble brewing, this then led to some form of knowledge seeking in order to improve care and improve the residents quality of life  some care aides indicated hesitancy to share their observations with others until they had been confirmed or validated either by further knowledge seeking/research on the part of the care aide, or confirmation by other staff that they were noticing the same thing, mainly other care aides  some care aides indicated that the more experienced they were, both with a particular resident and with being a care aide in general, the better they were able to “figure it out” or “wing it”, as the knowledge seeking process became more automatic and internalized  some of the care aides, in particular those with ESL, indicated that they prefer verbal passing of information, as it allows them to ask questions and seek clarification in the moment. It may also make for better quality of information, as there can be a tendency 149  to forget things over the course of a busy shift and talking them out with your coworker may prompt helpful memories  knowing more about each resident may help care aides to adapt their approaches and techniques, which in turn produces greater success with care, less distress for the resident, and less distress for the care aide  while some care aides referenced their previous education, and maybe even current use of textbooks from their initial training programs, as sources of information as to how to care for residents, most of the care aides indicated that things cannot be done “by the book” and need to be adapted moment to moment. They appeared to value experience and “common sense” over formal training  regular care aides indicated needed little information after admission/transition, casuals required information daily     150  Appendix J: Initial Codes    151  Appendix K- Mind Map Phase 3        152  Appendix L: Mind Map Phase 4     


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