Promoting autonomy and independence for older people within nursing practice: a literature review

Autonomy, independence, and participation of nursing home habitants addressed by assistive technology: a scoping review

CONTEXT

Assistive technologies have been identified by researchers and public policies of the Western world to be promising tools to face the challenge of maintaining quality of life of older people, and especially for nursing home habitants. Independence, autonomy, and participation are major determinants of quality of life of nursing homes habitants. Maintaining quality of life is nowadays a priority for public health policies and institutions of the where the population is growing older every year.

METHOD

This PRISMA-ScR review aims to determine which assistive technologies are used to promote autonomy, independence, and social participation of nursing home habitants. An electronic search was conducted for English, French articles to identify research studies using CINAHL, PubMed, Cochrane Library, PsycINFO, and Googlescholar.

RESULTS

12 papers published between 2009 and 2023 described 6 assistive technologies: technologies integrated into the environment, monitoring technologies, surveillance technologies, information and communication technology, social assistance robots, virtual reality. Six types of AT are currently used worldwide to maintain autonomy, independence and participation of people living in nursing homes. Their use is mainly perceived as positive by habitants, care and non-care staff, next of kin, and experts despite some concerns regarding ethical, financial, consideration.

DISCUSSION

Nevertheless, their impact on habitant's autonomy, independence and participation still needs to be measured using suitable tools to understand their real impact on the quality of life of the elderly.

Older Adults' Perspectives of Independence Through Time: Results of a Longitudinal Interview Study

BACKGROUND AND OBJECTIVES

Understanding how older people experience independence has implications for person-centered care. Existing understanding of older people's experience of independence, generated through methods that provide a "snapshot" view of a person's independence at a given time point, provides little insight into the process of maintaining independence through time. The aim of this study was to explore older participants' perceptions to understand the processes and resources that were most important for maintaining independence.

RESEARCH DESIGN AND METHODS

Two semistructured interviews were conducted longitudinally to explore the perspectives of 12 community-dwelling, older people, aged 76-85 years. A social constructivist approach, using dramaturgical and descriptive codes, facilitated the interpretation of the data. Sixteen analytical questions guided the exploration of participants' perceptions of independence through time.

RESULTS

Older people suggested that objective representations underestimated, and omitted, important aspects of their independence through time. Some participants perceived "snapshot" judgments of their independence as insensitive to their individual values and context. Change over time required some participants to adapt their methods for maintaining independence. The stability of participants' sense of independence was value dependent and informed by the purpose a participant ascribed to maintaining independence.

DISCUSSION AND IMPLICATIONS

This study augments the understanding of independence as a complex and multifaceted construct. The findings challenge the congruence of common interpretations of independence with older people's views, showing areas of commonality, and discrepancy. Exploration of independence in terms of form and function provides an important understanding of how function takes precedence to form in determining the maintenance of independence through time.

[Factors of endangering and violation of autonomy in residential nursing homes: results of a scoping review]

Background

Respecting autonomy is one of the guiding principles of medical and nursing ethics. Nursing home residents represent a particularly relevant target group whose autonomy can be endangered or violated.

Aim

The study aimed to identify factors that endanger or violate the nursing home residents' autonomy and to determine specific life situations and contexts in which these factors are located.

Methods

A scoping review was carried out according to the Joanna Briggs Institute-method. Empirical results from journal articles from the publication period 2000-2021 were included. The articles were analyzed using qualitative content analysis.

Results

A total of 75 articles were finally included in the review. Identified factors of the endangerment and violation of autonomy are assigned to topic areas located at the level of actors, (care) relationships and structures. Factors that can violate or endanger the residents' autonomy were found in the entire everyday life of the residents.

Conclusion

The localization of the identified endangerments/violations on various actor and structural levels indicates the need for comprehensive preservation and promotion of residents' autonomy in nursing homes.

Choosing and Managing Aged Care Services from Afar: What Matters to Australian Long-Distance Care Givers

This research aims to identify the factors that influence caregivers' decisions about the aged care providers they select for their elder relatives when caring from a distance and what they value once they have engaged a service. Adult long-distance carers for older relatives living within Australia were purposively sampled and they participated in audio-recorded interviews. A thematic analysis was employed to investigate the data. A sample of 13 participants enabled data saturation with no new major themes identified in the final three interviews. Participants were 50 to 65 years (Mean = 59.8) and mostly (77%) female. Four themes emerged relating to selection of care providers: (1) availability of care, (2) financial arrangements, (3) proximity and location, and (4) reputation of care provider. Five themes detailed valued qualities of care: (1) vigilant monitoring and responsivity, (2) communication with family, (3) flexibility and proactiveness of care, (4) staffing, and (5) access to appropriate and holistic care to maintain wellbeing. Long-distance caregivers face barriers in selecting and managing aged care services from afar within a complex Australian aged care system. They strongly value regular, proactive communication about the wellbeing of their relatives and may be particular beneficiaries of communication and assistive monitoring technologies.

The impact of community care services on the preference for ageing in place in urban China

This paper examines the relationship between community care services and ageing in place in urban China. Using data from the 2010 Sample Survey on Aged Population in Urban/Rural China, and within the framework of a revised version of Andersen's model, the paper applies multilevel models and analyses the effects of community care on the preference between ageing in place and institutional care, and reveals that ageing in place is preferred even in urban China. However, the existence of community care services had no significant effect on the preference for ageing in place. The paper concludes by arguing that China needs to develop its community care services and promote the idea of community care in both culture and policy. Realising ageing in place also requires a multidisciplinary approach. A model of shared care, between family and state, is particularly appropriate for China.

Resident Choice: A Nursing Home Staff Perspective on Tensions and Resolutions

A central component of person-centered care, resident choice in daily life, has received little research attention in the U.S.

CONTEXT

This study investigated nursing home staff experiences in realizing resident choice. Twenty-six qualitative staff interviews were conducted in an opportunistic sample from two Veterans Health Administration (VHA) Community Living Centers (CLCs, i.e., nursing homes) implementing the Green House Model. Thematic content analysis surfaced several key tensions at the intra-personal, inter-personal, and organizational levels. Most salient were staff mental models within the intra-personal level. Staff conveyed a lack of clarity on how to realize resident choice when faced with varying tensions, especially the competing goal of resident medical and safety needs. Staff-employed resolutions to resident choice-related tensions also emerged (e.g., preventive practices, staff reinforcement, and staff deliberation). This study offers specific and concrete insights on how resident choice in daily life, and thus resident quality of life, can be advanced.

Empowerment and disempowernent: Models of staff/patient interaction

This study aimed to develop valid models of empowerment and disempowerment relevant to staff/patient interaction as a means of generating a greater understanding of how these concepts are expressed in healthcare. This involved submitting the concepts of empowerment and disempowerment to an act frequency approach (Buss and Craik, 1983). Using this approach, registered nurses (n=38) were asked to nominate empowering and disempowering acts relevant to staff/patient interactions, yielding a list of 98 acts. Following this, older hospitalised people (n=20) were asked hypothetically to judge these acts as to the extent they would be 'control giving' if personally experienced. The 20 highest scoring acts for each concept were then incorporated into an act frequency observation scale. Using this composite scale, older hospitalised people (n=102) were asked to judge how often they had encountered each act over a pre-determined period of time. Act frequencies for each concept were then submitted to a principal components factor analysis.

The principal components of empowerment were identified as 'promoting patient independence,' 'promoting information exchange' and 'being aware of patient needs'; and for disempowerment, 'impeding patient collaboration in care planning,' 'domination' and 'indifference to patient needs'. Models of these concepts illustrate the therapeutic and non-therapeutic aspects of interpersonal care.

Finnish Nurses’ Interpretations of Patient Autonomy in the Context of End-of-Life Decision Making

Our aim was to study how nurses interpret patient autonomy in end-of-life decision making. This study built on our previous quantitative study, which evaluated the experiences of and views on end-of-life decision making of a representative sample of Finnish nurses taken from the whole country. We performed qualitative interviews with 17 nurses and analysed these using discourse analysis. In their talk, the nurses demonstrated three different discourses, namely, the ‘supporter’, the ‘analyst’ and the ‘practical’ discourses, each of which outlined a certain position for patients and relatives, and a certain identity for the nurses in end-of-life decision making. The nurses’ talk showed notable differences when compared with that of physicians, highlighting the differences that take place in respect of the image of a person’s work, professional culture, professional identification and responsibilities. An important finding was that the nurses often described their participation in end-of-life decision making in terms of indirect influence.

Correlates of Quality of Life in Older Adult Veterans

The purpose of this correlational study was to test theoretical propositions describing positive relationships between health promotion, sense of coherence, personal autonomy, and quality of life in older adult veterans and to explore their overall contribution to the prediction of quality of life. The sample consisted of 135 veterans aged 65 to 85 years who completed the Health-Promoting Lifestyle Profile, the Sense of Coherence-13 Scale, the Perceived Enactment of Autonomy Scale, and the Quality of Life Profile: Seniors Version, Short Scale. Health-promoting lifestyle, sense of coherence, and autonomy were positively correlated to quality of life. When the independent variables were subjected to a regression analysis, health-promoting lifestyle and autonomy explained 38% of the variance in quality of life.

Free choice in residential care for older people - A philosophical reflection

OBJECTIVE

Free choice in elderly care services is a debated issue. Using the theoretical support of philosophers of free will, this paper explores free choice in relocation to residential care. The three dominant perspectives within this field of philosophy, libertarianism, determinism and compatibilism, are applied from the perspective of the older individual to the process of moving.

METHOD

Empirical data were collected through qualitative interviews with 13 older individuals who had recently moved into residential care.

RESULTS

These individuals had made the choice to move following either a health emergency or incremental health problems. In a deterministic perspective they had no alternative to moving, which was the inevitable solution to their various personal problems. A network of people important to them assisted in the move, making the choice possible. However, post-move the interviewees' perspective had changed to a libertarian or compatibilist interpretation, whereby although the circumstances had conferred little freedom regarding the move.

CONCLUSIONS

The interviewees reported a high degree of self-determination in the process. It appeared that in order to restore self-respect and personal agency, the older individuals had transformed their restricted choice into a choice made of free will or freer will.

Evaluation of Quality of Life and Safety of Seniors in Golestan Province, Iran

This study evaluated the criteria for quality of life (QoL) using standardized short-form health survey with only 36 questions (SF-36; Version 2.0) and Consumer Product Safety Commission (CPSC) questionnaires to study the relationship between QoL and living conditions of seniors in Golestan province in Iran. This was an analytical cross-sectional study with descriptive and analytical parts. The population was individuals above 65 years of age in Golestan province in Iran. The sample size was calculated based on the correlation coefficient; a correlation of .2 or greater was considered statistically significant at 80% for the power of the test at the 95% confidence level. The data on QoL of seniors were collected by interview and observation using the CPSC questionnaire for nursing homes and the SF-36 for QoL health indicators. The reliability of the CPSC questionnaire was estimated using Cronbach’s alpha with a coefficient of .838. The SF-36 questionnaire was validated with Cronbach’s alpha with a coefficient of .95. Chi-square and logistic regression were used to interpret the probability of abnormal QoL between levels of independent predictors. The percentage of seniors in overall poor health as a binary outcome was 43.5, and the percentage of unsafe conditions was 49.8.

A cross-sectional study on person-centred communication in the care of older people: the COMHOME study protocol

INTRODUCTION

This paper presents an international cross-sectional study on person-centred communication with older people receiving healthcare (COMHOME). Person-centred care relies on effective communication, but few studies have explored this with a specific focus on older people. The main aim of the COMHOME study is to generate knowledge on person-centred communication with older people (>65 years) in home healthcare services, radiographic and optometric practice.

METHODS AND ANALYSIS

This study will explore the communication between care providers and older persons in home care services. Home healthcare visits will be audiorecorded (n=500) in Norway, the Netherlands and Sweden. Analyses will be performed with the Verona Coding Definitions for Emotional Sequences (VR-CoDES), the Roter Interaction Analysis System (RIAS) and qualitative methods. The content of the communication, communicative challenging situations as well as empathy, power distance, decision-making, preservation of dignity and respect will be explored. In Norway, an additional 100 encounters, 50 in optometric practice (video recorded) and 50 in radiographic practice (audiorecorded), will be analysed. Furthermore, healthcare providers' self-reported communication skills, empathy, mindfulness and emotional intelligence in relation to observed person-centred communication skills will be assessed using well-established standardised instruments.

ETHICS AND DISSEMINATION

Depending on national legislation, approval of either the central ethical committees (eg, nation or university), the national data protection officials or the local ethical committees (eg, units of home healthcare) was obtained. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. The research findings will add knowledge to improve services provided to this vulnerable group of patients. Additionally, the findings will underpin a training programme for healthcare students and care providers focusing on communication with older people.

Improving the quality of life for older people in long-term care settings

Many governments across Europe and America set maintaining the quality of life (QoL) of older people living in long-term care as a key policy objective; however, much of the evidence reveals that life in many care environments is still routinized and institutionalized. QoL is a term that is widely used but poorly defined and understood. The focus of this Review is on identifying the components of QoL and reviewing strategies for improving QoL in long-term care. Six components of QoL were consistently identified across studies: autonomy, environment, connectedness, meaningful activity, independence and sense of self. A review of strategies for improving QoL revealed that the evidence of effectiveness across studies remains inconclusive. The judgment of quality was often hampered by inadequate details on the study design and the use of nonspecific and wide-ranging QoL tools. Furthermore, high-quality studies are required to determine effectiveness.

Study protocol: translating and implementing psychosocial interventions in aged home care the lifestyle engagement activity program (LEAP) for life

BACKGROUND

Tailored psychosocial activity-based interventions have been shown to improve mood, behaviour and quality of life for nursing home residents. Occupational therapist delivered activity programs have shown benefits when delivered in home care settings for people with dementia. The primary aim of this study is to evaluate the effect of LEAP (Lifestyle Engagement Activity Program) for Life, a training and practice change program on the engagement of home care clients by care workers. Secondary aims are to evaluate the impact of the program on changes in client mood and behaviour.

METHODS/DESIGN

The 12 month LEAP program has three components: 1) engaging site management and care staff in the program; 2) employing a LEAP champion one day a week to support program activities; 3) delivering an evidence-based training program to care staff. Specifically, case managers will be trained and supported to set meaningful social or recreational goals with clients and incorporate these into care plans. Care workers will be trained in and encouraged to practise good communication, promote client independence and choice, and tailor meaningful activities using Montessori principles, reminiscence, music, physical activity and play. LEAP Champions will be given information about theories of organisational change and trained in interpersonal skills required for their role. LEAP will be evaluated in five home care sites including two that service ethnic minority groups. A quasi experimental design will be used with evaluation data collected four times: 6-months prior to program commencement; at the start of the program; and then after 6 and 12 months. Mixed effect models will enable comparison of change in outcomes for the periods before and during the program. The primary outcome measure is client engagement. Secondary outcomes for clients are satisfaction with care, dysphoria/depression, loneliness, apathy and agitation; and work satisfaction for care workers. A process evaluation will also be undertaken.

DISCUSSION

LEAP for Life may prove a cost-effective way to improve client engagement and other outcomes in the community setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612001064897.

Factors associated with nurses’ opinions and practices regarding information and consent

This cross-sectional survey aimed to investigate nurses’ opinions and practices regarding information and consent in the context of a large Italian teaching hospital and to explore potential influences of gender, age, university education, length of professional experience, and care setting. A questionnaire was administered to 282 nurses from six different care settings (Emergency Room, Emergency Medicine, Surgery, Hematology–Oncology, Geriatrics, and Internal Medicine). Overall, 84% (n = 237) of nurses returned the questionnaire (men: 24%; mean age: 36.2 ± 8 years; university degree: 35%; mean length of professional experience: 12 ± 8.2 years). Most respondents regularly informed patients about medications and nursing procedures and asked for consent prior to invasive procedures, but some provided information to relatives instead of patients. Lack of time or opportunity was the main difficulty in informing patients. The work setting was the foremost factor significantly associated with participants’ opinions and practices. Further investigations are needed to confirm these findings in similar and other care settings.

Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP)

BACKGROUND

Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated.

OBJECTIVE

To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR).

METHODS

We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups.

RESULTS

We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program.

CONCLUSIONS

This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.

Nursing staff's movement awareness, attitudes and reported behaviour in patient transfer before and after an educational intervention

The objective was to evaluate changes after a two half-day patient transfer course regarding nursing staff's movement and body awareness, attitudes, reported behaviour, strain, disorder and sick leave. The course aimed at increasing staff's self-awareness of movements and body, and their communication competence, with the intention to promote the patient's independent mobility. Ninety-nine staff in an intervention group and 77 staff in two control groups answered a questionnaire before and after the intervention. After one year there was a significant increase in the number of instructions given and nursing staff's movement awareness in the intervention group compared to the control group. Reported physical disorders decreased significantly in the intervention group compared with both control groups. Increased movement awareness and frequent use of instructions during transfers may encourage patients to move independently and thereby reduce the strain in nursing staff.

Violation of ethical principles in institutional care for older people

This study focuses on issues of elder abuse in residential settings. Violation of ethical principles is shown in the results of this quantitative study aimed at defining the extent, nature and causes of such abuse by employees’ unethical conduct towards clients in senior homes (i.e. residential nursing homes) in the Moravian-Silesian region of the Czech Republic. The research sample comprised 454 employees and 488 clients from 12 residential homes for older people. The data were collected from interviews with clients, who also received a questionnaire concerning their satisfaction with the institution. Two questionnaires were administered to the employees, one based on a pilot qualitative study and a second to investigate burnout. Outcomes were assessed according to the extent and form of elder abuse, the causes of elder abuse and the violation of basic ethical principles. The responses, in particular those of employees, revealed both psychological and physical abuse of older clients, and thus violation of two basic principles: respect for the person and non-maleficence. The group at risk of elder abuse comprised aggressive and dissatisfied clients, as well as those with mental problems and dementia. The employees most at risk of being abusers were those who had been employed in institutional care for more than five years, had inadequate knowledge about social services and suffered from burnout. The prevention of elder abuse is recommended to be through education focused on ethical principles, increasing employees’ satisfaction by promoting a friendly and safe organizational culture, and providing adequate working conditions.

Factors influencing older patients' participation in care: a review of the literature

BACKGROUND

Over the past 10 years, there has been an increase in the literature promoting patient involvement in health care at all levels of the decision-making process.

AIM

To review the literature on factors influencing patient participation in care with a particular focus on the perspective of older people.

METHOD

Various search engines were used to conduct the review and articles were identified through the following databases; CINAHL, CSA ILLUMINA, Science Direct, Blackwell Synergy, the Cochrane Library, OVID, SAGE, AHMED, BNI and MEDLINE. Research studies ranging from 2000-2007 were selected for inclusion on the basis that they investigated patient participation and/or older peoples' involvement in health care.

FINDINGS

Seven key themes emerged from the literature: the concept of participation, the need for older people to be involved, autonomy and empowerment, patients' expectations, benefits of participation, factors influencing participation and precursors to participation.

CONCLUSIONS

Although patient participation has received considerable attention in the literature, this review highlights the dearth of research from the perspective of older people. There is a general consensus that preference for participation should be assessed and not assumed, and the review offers a sobering reminder that participation should not be achieved at the expense of patient autonomy and choice.

RELEVANCE TO PRACTICE

Quality care and the most productive use of resources are dependent on the public's engagement with health service providers. However, despite being central to contemporary nursing practice, this review suggests that the reality is not matched by the rhetoric. Future initiatives should focus on supporting nurses and other healthcare professionals to develop the competencies required to facilitate greater participation by older people who wish to become more involved in their care.

'Help me! I'm old!' How negative aging stereotypes create dependency among older adults

OBJECTIVES

This study examined the effects of negative aging stereotypes on self-reported loneliness, risk-taking, subjective health, and help-seeking behavior in a French sample of older adults. The aim of this study was to show the detrimental effects of negative aging stereotypes on older adults' self-evaluations and behaviors, therefore contributing to the explanations of the iatrogenic effect of social environments that increase dependency (e.g., health care institutions).

METHOD

In the first experiment conducted on 57 older adults, we explored the effects of positive, neutral, or negative stereotype activation on the feeling of loneliness and risk taking decision. The second experiment (n = 60) examined the impact of stereotype activation on subjective health, self-reported extraversion as well as on a genuine help-seeking behavior, by allowing participants to ask for the experimenter's help while completing a task.

RESULTS

As predicted, negative stereotype activation resulted in lower levels of risk taking, subjective health and extraversion, and in higher feelings of loneliness and a more frequent help-seeking behavior.

CONCLUSION

These findings suggest that the mere activation of negative stereotypes can have broad and deleterious effects on older individuals' self-evaluation and functioning, which in turn may contribute to the often observed dependency among older people.

Development of the Nursing Relationships Scale: a measure of interpersonal approaches in nursing care

Background

There is no comprehensive measure of dimensions describing the nursing relationship that is suitable for use with survey samples and that is focused on nursing particular types of patients. The objective of this study was to develop a measure to investigate significant dimensions of the nurse-patient relationship, the Nursing Relationship Scale (NRS).

Methods

Hypothetical cases (diabetes or mental illness) in vignette format were presented to 132 psychiatric and 76 general nurses. Thirty-four questions about the nurse-patient interaction were asked. Principal component analyses (with oblique rotation) were used to identify underlying dimensionality in the correlations of items, combining ratings from the two case vignettes. Scales were constructed from the final solution and Cronbach's alpha coefficients calculated. Subscale score variations were analysed across nurse type and patient type to examine the discriminant validity of the subscales.

Results

Principal components analysis revealed five dimensions accounting for 52 percent of the variation within items. Four 'conceptual' factors were derived. These were labeled Caring/Supportive Approach, Nursing Satisfaction, Authoritarian Stance, and Negativity. Developed as subscales, reliability analysis indicated high internal consistency with respective alpha coefficients for the diabetes case 0.91, 0.75, 0.65, and 0.78 and for the mental illness case of 0.91, 0.75, 0.73, and 0.85. There was significant variation in scale scores according to nurse type (psychiatric versus general) and patient type (diabetes versus mental illness). Nurses endorsed more highly items from the subscales Caring/Supportive Approach and Nursing Satisfaction than items from Authoritarian Stance (with intermediate endorsement) and Negativity (lowest endorsement) subscales.

Conclusions

Psychometric evaluation of the NRS suggests it is a reliable instrument for measuring four key dimensions of the nurse-patient relationship and enables the study of this relationship in large samples.

The clinical utility of the Care Dependency Scale in rehabilitation: nurses’ perception

Increasing costs within health care require an efficient use of time and staff in order to appropriately satisfy patients’ needs. The application of valid and reliable instruments enables nurses to determine patients’ care needs. However, to ensure acceptance in nursing practice, assessment instruments must not only be reliable and valid, but also practical and useful. One such instrument for rehabilitation is the Care Dependency Scale for rehabilitation. The scale has been used in rehabilitation, but so far it has not been evaluated from the nurses’ perspective. Therefore, this study aims to determine how nurses evaluate the clinical utility of the Care Dependency Scale for rehabilitation. In this context the application and testing of a staff view assessment instrument was deemed necessary, and this constitutes the second aim of the study. Nurses from several Austrian rehabilitation units were asked to complete the staff view assessment instrument to evaluate the Care Dependency Scale for rehabilitation. Ethical approval was obtained. Results indicate that the staff view assessment instrument enables evaluation of the clinical utility of the Care Dependency Scale for rehabilitation. Most nurses agree that the Care Dependency Scale for rehabilitation is a clinically useful instrument, improves communication and cooperation within the nursing team and is easy and quick to use/analyse/ interpret. It may therefore be recommended for application in daily nursing practice.

Perceived Autonomy and Activity Choices Among Physically Disabled Older People in Nursing Home Settings: A Randomized Trial

Objectives: To evaluate the effect of individually tailored programs on perceived autonomy in institutionalized physically disabled older people and to describe participants’ activity wishes and content of the programs. Method: This blinded randomized trial with follow up included a total of nine nursing homes and 50 nursing home residents who were randomized into either a control group or an intervention group. Perceived autonomy was measured at baseline (T1), after 12 weeks (T2) of intervention and after 24 weeks (T3) Wishes for daily activities was identified at T1. Weekly reports of individual programs were drawn up. Results: Both groups perceived autonomy as average at baseline and increased their mean score at T2 to high or close to high. At T3, both groups scored average but exceeded the level of T1. Activity wishes and the content of the programs indicate incoherence. Discussion: Although the correspondence between the individual wishes for activities and the concrete content of the programs was not obvious, results indicate potential for enabling the perception of autonomy among physically disabled older nursing home residents. The clinical consequences may suggest a focus on existing traditions, methods, and tools in the nursing home practice.

Ethical Values in Personal Assistance: Narratives of People with Disabilities

The aim of this study was to investigate the experiences of persons with severe functional disabilities who receive personal assistance in their homes, the focus being on their daily life in relation to the ethical principles represented in the Swedish Disability Act: autonomy, integrity, influence and participation. Qualitative interviews were performed with 26 persons and thereafter subjected to qualitative latent content analysis. The experiences of personal assistance were very much in accordance with the said principles, the most important factor being that one is met with understanding. The participants described situations in which their integrity was violated in that they were not treated as competent adults. This indicates the importance of future efforts in nursing to support personal assistants with ethical knowledge and supervision so that they can empower people with disabilities and thereby enable them to maintain their self-esteem and dignity.

Building empowering partnerships for interprofessional care

While partnership approaches have the potential to achieve cost-effective quality health care, several attributes of the current context make partnerships difficult to achieve. This paper provides an analysis of the socio-cultural, structural and human challenges to building partnerships at both personal and organizational levels, together with an empowering interdisciplinary approach for overcoming these barriers. Premised on empirical evidence, 'flexible client-driven care', currently being tested in the home care sector in Canada, encompasses structures and processes that promote relationship-building and conscientious critical application of individual and collective potential for achieving health care. Strategies for implementing empowering partnership-building at both personal and organizational levels are elaborated, together with the challenges encountered. The practical issues addressed afford insights and ideas for others who may be attempting to achieve similar partnership aims.

Elder Abuse and Mistreatment in Residential Settings

Older people living in a residential setting have the right to respectful care based on professional ethics. The aim of this study was to describe employees' and clients' lived experiences of elder abuse. A qualitative phenomenological method was used with 26 employees and 20 residents from four homes for elderly people in the town of Ostrava, Czech Republic, and two managers from outside these institutions. All complaints about elder abuse ( n 5 11) received by Ostrava Municipal Authority during the period 2003 to 2007 were examined. Two main dimensions of the examined phenomenon were identified: forms of elder abuse and causes of elder abuse. Established forms of elder abuse were summarized as rights violation, financial abuse, psychological abuse, physical abuse and neglect. Causes of elder abuse included institution, employee and client characteristics. It is necessary in residential settings to create preventive policies that will focus on supervision regarding elderly people's rights violation and psychological and physical abuse, as well as on building organizational cultures that will respect ethical principles.

Autonomy among physically frail older people in nursing home settings: a study protocol for an intervention study

BACKGROUND

Experiencing autonomy is recognised to promote health and well-being for all age groups. Perceived lack of control has been found to be detrimental to physical and mental health. There is a lack of evidence-based knowledge elucidating how frail older people in nursing home settings themselves perceive autonomy in daily life. Further, there are no studies on the extent to which this perception can be influenced positively by participating in an individually tailored programme based on residents' own wishes for daily activities.

METHODS AND DESIGN

A total of 9 nursing homes and 55 participants aged 65 years or older were included in the study. All the participants were restricted in performing at least one P-ADL activity unassisted and had a Mini Mental State Examination-score above 16. Perceived autonomy was measured at baseline, after 12 weeks and after 24 weeks by The Autonomy Sub-dimension in the Measure of Actualisation of Potential test. Programmes were based on participants' individual assessment of their most important daily activities. Staff at all nursing homes who usually organize physical training, social or creative activities carried out individually tailored programmes using their usual methods and equipment. Participants in each nursing home were divided by lot into either a control group or an intervention group. The control groups received their usual care and treatment.

DISCUSSION

This study is designed to assess the status of perceived autonomy at baseline and to provide information about the effectiveness of individually tailored programmes according to perceptions of autonomy registered in institutionalised physically frail older people. This will add knowledge to assist response to present and future challenges in relation to health promotion initiatives for this group.

Patient perceptions having suffered a stroke in Galway

Of the estimated 10,000 people annually who have a stroke in Ireland, about 7500 will continue to live with some residual disability. This study explored older people's perceptions of health, level of independence as well as the factors that enhanced or diminished ability to maintain quality of life after stroke. A grounded theory approach was used and 20 stroke survivors were interviewed. Analysis of the data revealed three main themes: concepts of health and independence, sense of loss, and environmental factors. Despite their disability most participants continued to have a positive concept of health. Participants overall adopted a functional approach toward independence and those with severe disabilities felt less independent. Many reported a profound sense of loss in terms of identity and role function. Environmental factors including availability of transport and social connections had a significant impact on quality of life. Most participants appeared to be struggling to adapt to their disability and subsequent experiences in a rather unsupportive environment.

Involvement of older people in care, service and policy planning

In line with other helping professions nursing has moved from traditional views of technical expertise as the prime shaper of health care, to a more equal relationship with service users and patients which respects their expertise, knowledge, goals and choices. This philosophy has underpinned the movement to involve older people in care, policy and planning activities. The literature review presented in this paper highlights the growing literature on this subject with respect to older people and maps the key issues and debates for nursing.

Perceived autonomy and self-care resources among senior center users

Personal autonomy-the ability to make freely self-directed choices in one's life-is considered critical to an older person's quality of life. Informed by model and role-modeling nursing theory, this descriptive, correlational study examined the relationship of perceived enactment of autonomy to self-care resources, both internal (age, race, functional ability) and external (social support, living arrangements, community-based service utilization, and service satisfaction) among 120 older adults from 6 Manhattan senior centers. Participants demonstrated positive perceived autonomy. Study participants used a variety of community-based services, and their satisfaction with the services was significantly linked to autonomy. Using multiple linear regression model, the only significant predictors of perceived autonomy were race (white > nonwhite), service satisfaction, and social support. Nursing strategies such as providing information that promotes informed decision making and encouraging independence, as well as working collaboratively with members of an older persons' social network, can enhance an older persons' autonomy.

Self-evaluation and peer review--an example of action research in promoting self-determination of patients with rheumatoid arthritis

AIMS AND OBJECTIVES

The aim of this paper was to describe the areas that have been performed well and the areas in need of further development of rheumatoid arthritis patients.

BACKGROUND

Nurses' self-evaluation and peer review are important methods for ascertaining the changes and success in the development of nursing practice. To date, there has been minimal research regarding the use of those evaluation methods in nursing practice.

DESIGN

The findings of self-evaluation and peer review of nurses are described in a participatory action research study aimed at promotion of self-determination for patients with rheumatoid arthritis.

METHODS

In self-evaluation, the collection of data was accomplished using a self-evaluation instrument with the permanent nursing staff (n = 18), then analysed through quantitative methods. For peer review, the data were gathered through focus groups (n = 21) using a tool similar to the one used for self-evaluation. The participants included many of the same nurses as in self-evaluation. The data were analysed using qualitative content analysis.

RESULTS

Well-performed areas in nursing of rheumatoid arthritis patients were found to be promoting patient participation, supporting self-determination, performing patient-centred nursing and raising patient self-respect. The areas in need of development were connected to the nursing staff themselves: increasing collaboration of nursing staff, decreasing authoritarianism in nursing care and developing nursing practice with colleagues.

CONCLUSIONS

Self-evaluation and peer review are complementary and support one another, especially since nurses were found to be more critical in their self-evaluations than in peer review.

RELEVANCE TO CLINICAL PRACTICE

Both evaluation tools proved to be useful methods in the evaluation phase of the action research process as a means of professional development. Also assisting in the development of clinical nursing practice.