Risk: ‘I know it when I see it’: how health and social practitioners defined and evaluated living at risk among community-dwelling older adults

Shifting the narrative from living at risk to living with risk: validating and pilot-testing a clinical decision support tool: a mixed methods study

BACKGROUND

When there are safety concerns, healthcare professionals (HCPs) may disregard older adults' wishes to return or remain at home. A paradigm shift is needed for HCPs to move from labelling older adults as living at risk to helping them live with risk. The Living with Risk: Decision Support Tool (LwR:DST) was developed to support older adults and HCPs with difficult decision-making regarding living with risk. The study objectives were to: (1) validate, and (2) pilot-test the LwR:DST in hospital and community settings.

METHODS

The study was conducted across Canada during the pandemic. The LwR:DST's content was validated with quantitative and qualitative data by: (1) 71 HCPs from hospital and community settings using the Delphi method, and (2) 17 older adults and caregivers using focus groups. HCPs provided feedback on the LwR:DST's content, format and instruction manual while older adults provided feedback on the LwR:DST's communication step. The revised LwR:DST was pilot-tested by 14 HCPs in one hospital and one community setting, and 17 older adults and caregivers described their experience of HCPs using this approach with them. Descriptive and thematic analysis were performed.

RESULTS

The LwR:DST underwent two iterations incorporating qualitative and quantitative data provided by HCPs, older adults and caregivers. The quantitative Delphi method data validated the content and the process of the LwR:DST, while the qualitative data provided practical improvements. The pilot-testing results suggest that using the LwR:DST broadens HCPs' clinical thinking, structures their decision-making, improves their communication and increases their competence and comfort with risk assessment and management. Our findings also suggest that the LwR:DST improves older adults' healthcare experience by feeling heard, understood and involved.

CONCLUSIONS

This revised LwR:DST should help HCPs systematically identify frail older adults' risks when they remain at or return home and find acceptable ways to mitigate these risks. The LwR:DST induces a paradigm shift by acknowledging that risks are inherent in everyday living and that risk-taking has positive and negative consequences. The challenges involved in integrating the LwR:DST into practice, i.e., when, how and with whom to use it, will be addressed in future research.

Pilot validation of a verbal practical judgement assessment (VPJ) among community-dwelling older adults in Israel: the first step toward a national standard

Increased longevity and subsequent increase in older populations emphasize the importance of assisting older people to continue living in safe and residential situations for as long as possible. Judgement, an important aspect of cognition, and a predictor of function may become impaired and compromise safe living. Yet, judgement is difficult to assess, and few valid instruments are utilized in clinical settings that accurately evaluate judgement in older people.

Objectives

This pilot study aimed to translate, culturally adapt, and initiate the validation of the Hebrew version of the verbal practical judgement (VPJ) assessment among community-dwelling older people.

Methods

A total of 50 older adults, aged over 65 years, living in the community in Israel, half of whom were independent (n=27, 54%), and the rest dependent participants in a day centre with some level of cognitive/functional decline, completed the VPJ evaluation and comparison assessments.

Results

Positive and significant (p<0.05) relationships between VPJ and standard assessments were found, demonstrating convergent validity. By comparing VPJ scores between independent and dependent older adults, results also supported discriminant validity. Finally, a multiple hierarchical regression demonstrated a positive relationship between instrumental activities of daily living and judgement.

Conclusions

This pilot study found the VPJ feasible, likely valid, and culturally adaptable to assess judgement in Israeli older adults. Assessing judgement will provide older adults and their families with essential information regarding function, cognition, and safety and will enable them to live/return home in accordance with their autonomy, safety, and well-being.

Risks Perceived by Frail Male Patients, Family Caregivers and Clinicians in Hospital: Do they Change after Discharge? A Multiple Case Study

INTRODUCTION

Up to 40% of hospitalised seniors are frail and most want to return home after discharge. Inaccurate estimation of risks in the hospital may lead to inadequate support at home. This study aimed to document convergences and divergences between risks and support needs identified before hospital discharge and perceived at home post-discharge.

METHODS

This research used a multiple case study design. Three cases were recruited, each involving a hospitalised frail patient aged 70+, the main family caregiver and most of the clinicians who assessed the patient before and after hospital discharge. Thirty-two semi-structured interviews were conducted and their transcripts analysed using a qualitative thematic analysis approach.

RESULTS

Among risks raised by participants, falls were the only one with total inter-participant/inter-time/inter-case convergence. In all cases, all participants mentioned, before and after discharge, home adaptations and use of technical aids to mitigate this risk. However, clinicians recommended professional services while patients and family caregivers preferred to rely on family members and their own coping strategies.

CONCLUSION

The divergences identified for most risks and support needs between users and clinicians, before and after discharge, provide new insights into a comprehensive and patient-centred risk assessment process to plan hospital discharge for frail elderly.

SÉCuRE: A clinical tool for comprehensively assessing home safety of people with mental illness

Introduction

People with severe mental illness benefit from a growing number of measures aimed at supporting independent housing. The purpose of the study was to develop a comprehensive home safety assessment tool.

Method

The tool's elaboration was done in three phases. The planning phase was intended to circumscribe the phenomenon, providing input for the development phase, which consisted of creating and enhancing the tool's prototypes. The evaluation phase then featured the tool's translation validity (relevance, exhaustiveness, clarity, and apparent clinical utility), with four successive rounds of expert consultation ( n = 20). Changes were made to the tool according to the experts' suggestions.

Findings

The proposed tool, SÉCuRE, adopts a structured professional judgment approach that is designed to be used collaboratively and interprofessionally, with a specific role for occupational therapists. It aims to systematize the assessment of contributive factors (risk and protective), all stakeholders' expectations and needs and the identification of potential ethical issues. The findings supported the translation validity and acceptance of the tool by clinicians.

Conclusion

SÉCuRE was developed to assist with clinical judgment regarding home safety interventions. It is hoped that its use may ultimately foster home safety in the context of recovery.

'Everyone has an agenda': Professionals' understanding and negotiation of risk within the Guardianship system of Victoria, Australia

It is frequently asserted that pressures to assess and manage risk have eroded the therapeutic, rights-based foundation of the human services profession. Some argue that human service workers operate in a culture of fear in which self-protection and blame avoidance, rather than clients' needs, primarily drive decision-making. In the field of Adult Guardianship, it has been suggested that organisational risk avoidance may be motivating applications for substitute decision-makers, unnecessarily curtailing clients' rights and freedoms. However, the absence of research examining the operation of risk within Guardianship decision-making inhibits verifying and responding to this very serious suggestion. This article draws on semi-structured interviews conducted with 10 professionals involved in the Victorian Guardianship system, which explored how issues of risk are perceived and negotiated in everyday practice. Risk was found to be a complex and subjective construct which can present both dangers and opportunities for Guardianship practitioners and their clients. While a number of participants reported that Guardianship might sometimes operate as an avenue for mitigating the fear and uncertainty of risk, most participants also valued positive risk-taking and were willing, in their clients' interests, to challenge conservative logics of risk. These findings highlight the need for further research which examines how service providers and policy makers can create spaces that support open discussions around issues of risk and address practitioners' sense of fear and vulnerability.

'I'd rather die happy': residents' experiences with food regulations, risk and food choice in residential aged care. A qualitative study

BACKGROUND

Food regulations exist to protect older people in residential aged care, leading to the restriction of potentially hazardous foods. The impacts of malnutrition, resident centred care and the importance of maintaining individual autonomy for older people are well documented. By contrast, there is scant literature describing residents' perceptions of food regulations and food risks in the residential aged care setting.

AIMS

The aim of this study is to explore resident perceptions of food choice and food restrictions in residential aged care.

METHODS

Using a qualitative, hermeneutic phenomenological design, semi-structured interviews were conducted with six participants recruited from two residential aged care facilities. Interviews were audio-taped, transcribed verbatim and thematically analysed.

RESULTS

The following key themes emerged in this study: participants were largely unaware of food regulations and risks, yet expressed the desire to make their own choices. Participants provided contradictory accounts of their experiences with food in residential aged care, which emphasises the ongoing challenge of meeting individual preferences.

CONCLUSION

These themes warrant further investigation, particularly in relation to the impact of food regulations on food choice and the meaning of risk to older people in residential aged care. This research provides new insight into the perceptions of residents regarding their individual autonomy and independence against legislated risk minimization strategies. Impact statement This article raises the issue of risk taking and food choices from the perspective of residents in a residential aged care facility.

Shaping risky choices: Ethics and the effects of organizational decisions

Choices to live "at risk" are complex and challenging and can be structured by organizational policy. Some individuals genuinely wish to live in situations that are, or are perceived to be, high risk because this affords them an important benefit. However, it is likely that these choices are significantly affected by context and might not be made under different circumstances. The following argues for a responsibility to be attentive to the effects of organizational decisions on choices to live at risk and the overall distribution of risk.

Définir les choix à risque: l'éthique et les effets des décisions organisationnelles

Les choix de vivre « à risque » sont complexes et difficiles. Ils peuvent être structurés par les politiques organisationnelles. Certaines personnes veulent vraiment vivre dans des situations à haut risque ou perçues comme telles parce qu'elles en tirent un avantage important. Cependant, il est probable que ces choix dépendent en grande partie du contexte et qu'ils ne se soient pas posés dans une autre situation. L'article plaide pour la responsabilité d'être attentif aux effets des décisions organisationnelles sur les choix de vivre à risque et sur la répartition globale du risque.

Perception of risk for older people living with a mental illness: Balancing uncertainty

Risk is commonly defined as a negative threat which needs to be controlled and mitigated; as a concept, it takes high priority in contemporary mental health services. Health-care organizations and clinicians are now required to use levels of risk as a benchmark for clinical decision-making. However, perceptions of risk change according to the lens through which it is viewed. A qualitative, exploratory research study was undertaken in an aged persons' mental health programme in Victoria, Australia, to explore the notion of risk from the multiple perspectives of service providers and consumers. Data were obtained through in-depth interviews, and analysis was based on the framework of Ritchie and Spencer. Balancing uncertainty emerged as a major theme, and comprised two subthemes: (i) complexity of risk from the perspective of providers of services; and (ii) complexity of safety from the perspectives of recipients of services. These differences emphasize a significant disjuncture between perceptions of risk and the potential for the individual needs and concerns of consumers to be subsumed under broader organizational issues. The uncertainty this tension highlights suggests the need to reconceptualize risk, incorporating the views and experiences of all stakeholders, particularly consumers and carers, to enhance recovery-oriented services and facilitate consumer participation within mental health services.