Impediments to applying the ‘dignity of risk’ principle in residential aged care services

Validation of an Instrument That Measures Factors Affecting Saudi Parents' Tolerance of Risky Play: A Rasch Analysis

IMPORTANCE

Benefits of children's participation in risky play are broadly recognized. However, most related research originates in Western countries; none focuses on outdoor play in Eastern countries, including Saudi Arabia. Furthermore, although the literature identifies varying perspectives on risky play among parents, there is no objective measure to assess personal, situational, and cultural factors shaping their risk tolerance.

OBJECTIVE

To establish the construct validity and internal reliability of data gathered with the newly developed Factors Affecting Tolerance for Risk in Play Scale (FAC-TRiPS).

DESIGN

Instrument development.

SETTING

Online survey.

PARTICIPANTS

Ninety Saudi parents with children ages 7 to 10 yr.

OUTCOMES AND MEASURES

The FAC-TRiPS, a 17-item, self-report measure. We used Rasch analysis (Winsteps 4.4.4) to establish evidence for construct validity (item fit, match of item difficulty and parent tolerance, principal-components results) and internal reliability (person reliability index).

RESULTS

Item fit analysis revealed that data from 15 of 17 items (88%) conformed to Rasch model expectations. Item difficulty closely matched parents' risk tolerance level. The principal-components analysis of residuals demonstrated that observed variance (49.6%) closely matched expected variance (49.7%). The first contrast's unexplained variance had an eigenvalue slightly greater than 2.5, suggesting possible multidimensionality. The person reliability index was .90.

CONCLUSIONS AND RELEVANCE

Preliminary analysis suggests that the FAC-TRiPS yields valid, reliable data measuring factors that influence parents' risk tolerance. Further research is needed. Plain-Language Summary: This study contributes to the knowledge of how parents in Eastern countries perceive risky play. The Factors Affecting Tolerance for Risk in Play Scale (FAC-TRiPS) is a newly developed tool that occupational therapy practitioners can use to understand parents' beliefs about and tolerance for their children's participation in risky play. The findings facilitate an understanding of the complex nature of parenting when determining whether to allow children to participate in risky play activities.

'It's like home' - A small-scale dementia care home and the use of technology: A qualitative study

AIM

To explore the experiences of residents, families and staff in the establishment of a new small-scale home model of care for people living with dementia.

BACKGROUND

New and innovative small-scale models of care have the potential to improve outcomes for older people, especially those with dementia, who experience high rates of cognitive impairment in traditional residential aged care homes in Australia.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured interviews with 14 guests, family and staff of a new small-scale dementia home named 'Kambera House' in the Australian Capital Territory were conducted between July 2021 when the home opened and August 2022. Data were analysed using reflexive thematic analysis and reported according to the COREQ guidelines.

RESULTS

Two guests with mild-to-moderate dementia, five family and seven staff members participated in the study. The data revealed high satisfaction with Kambera House, generating five themes. Falls detection technology in the home provided a sense of safety, enabling more time for person-centred care. Free, everyday technology connected the home with families as part of an overall community of care where staff were empowered to maximize choice and dignity of risk of guests living in the home. This contributed to the sense of community, rather than an institution, where the conditions of work supported the conditions of care, and were embedded in a culture of responsiveness, change and flexibility.

CONCLUSION

Kambera House represents a successful example of a new small-scale dementia home. Technology played an important background role in improving overall safety and flexibility as part of a model of care which demonstrated positive experiences for guests and families by being responsive to their individual needs.

IMPACTS

Small-scale homes for people with dementia offer an alternative model that may provide more individualized, person-centred care compared with the traditional institutionalized care.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Designing an Alternative, Community Integrated Model of Residential Aged Care for People Living with Dementia: Nominal Group Technique and Thematic Analysis

BACKGROUND

Small-scale models of dementia care are a potential solution to deinstitutionalize residential aged care and have been associated with improved resident outcomes, including quality of life and reduced hospitalizations for people living with dementia.

OBJECTIVE

This study aimed to generate strategies and ideas on how homes for people living with dementia in a village setting within a suburban community, could be designed and function without external boundaries. In particular, how could residents of the village and members of the surrounding community access and engage safely and equitably so that interpersonal connections might be fostered?

METHODS

Twenty-one participants provided an idea for discussion at three Nominal Group Technique workshops, including people living with dementia, carers or former carers, academics, researchers, and clinicians. Discussion and ranking of ideas were facilitated in each workshop, and qualitative data were analyzed thematically.

RESULTS

All three workshops highlighted the importance of a surrounding community invested in the village; education and dementia awareness training for staff, families, services, and the community; and the necessity for adequately and appropriately trained staff. An appropriate mission, vision, and values of the organization providing care were deemed essential to facilitate an inclusive culture that promotes dignity of risk and meaningful activities.

CONCLUSION

These principles can be used to develop an improved model of residential aged care for people living with dementia. In particular, inclusivity, enablement, and dignity of risk are essential principles for residents to live meaningful lives free from stigma in a village without external boundaries.

A Scoping Review of Adverse Incidents Research in Aged Care Homes: Learnings, Gaps, and Challenges

Background: Adverse incidents are well studied within acute care settings, less so within aged care homes. The aim of this scoping review was to define the types of adverse incidents studied in aged care homes and highlight strengths, gaps, and challenges of this research. Methods: An expanded definition of adverse incidents including physical, social, and environmental impacts was used in a scoping review based on the PRISMA Extension for Scoping Reviews Checklist. MEDLINE, CINAHL, and EBSCOhost were searched for English language, peer-reviewed studies conducted in aged care home settings between 2000 and 2020. Forty six articles across 12 countries were identified, charted, and analyzed using descriptive statistics and narrative summary methods. Results: Quantitative studies (n = 42, 91%) dominated adverse incidents literature. The majority of studies focused on physical injuries (n = 29, 63%), with fewer examining personal/interpersonal (15%) and environmental factors (22%). Many studies did not describe the country's aged care system (n = 26, 56%). Only five studies (11%) included residents' voices. Discussion: This review highlights a need for greater focus on resident voices, qualitative research, and interpersonal/environmental perspectives in adverse event research in aged care homes. Addressing these gaps, future research may contribute to better understanding of adverse incidents within this setting.

Occupational therapists and physiotherapists weighing up the dignity of risk for people living with a brain injury: grounded theory

PURPOSE

Following a brain injury survivors may have physical, or cognitive changes or behaviours which bring safety risks into play when engaging in activities. Therapists experience tensions in enabling the dignity of participation in the context of managing risk.

MATERIALS AND METHODS

Ten occupational therapists and seven physiotherapists participated in a grounded theory study utilising semi-structured in-depth interviews to explore the tensions between dignity and management of safety risks. Data were analysed using constant comparative method and a process of moving from open coding to categories to theory development.

RESULTS

The process of weighing up was central to the therapists' approach to supporting dignity while managing risk. Respecting dignity itself is placed at risk when preventing harm is weighted higher than living a full life. Therapists who use weighing up as a process that respects dignity place greater value on the principles of respecting autonomy and promotion of justice for people with a brain injury.

CONCLUSION

Rather than taking control and attempting to minimise risk therapists who privilege the perspective of the client, and provide opportunities for learning through failure or success, enable clients to live a full life.IMPLICATIONS FOR REHABILITATIONEnsuring that clients with brain injury are safe often requires therapists to exercise control and remove agency thus removing the rights of the client to the dignity of risk and living a full life.Providing opportunities within rehabilitation for clients to experience failure and success enables learning and thereby support dignity.Privileging the client perspective provides clients the dignity of living a normal life.

Nursing Staff Perceptions of Outcomes Related to Honoring Residents' "Risky" Preferences

Nursing homes (NHs) are challenged to consistently deliver person-centered care (PCC), or care based on residents' values and preferences. NH staff associate certain resident preferences with risk. However, there are limited evidence-based person-centered risk management strategies to assist NH staff with risky resident preferences. The purpose of the current study was to explore NH staff perceptions of health and safety outcomes associated with honoring NH residents' risky preferences to inform intervention development. This descriptive, qualitative study used sequential focus groups and content analysis, revealing that nursing staff perceive negative and positive outcomes for staff and residents when seeking to honor residents' risky preferences. This finding is supported by three themes: Potential Harms to Staff, Potential Harms to Residents, and Positive Shared Outcomes. These results contribute a set of nurse-driven quality of life and quality of care outcomes for NH staff and residents associated with PCC delivery in NHs. [Research in Gerontological Nursing, 15(6), 271-281.].

"Making an effort for the very elderly": The acceptability of a multidisciplinary intervention to retirement village residents

The retirement village (RV) population is a growing one, with many residents having unmet healthcare needs. Despite this, there is a relative paucity of research in the RV community. We previously performed a randomised controlled trial (RCT) of a multidisciplinary (MD) nurse-led community intervention versus usual care within 33 RVs in Auckland, New Zealand. Participant acceptability is an important aspect in assessing intervention feasibility and effectiveness. The aim of this current qualitative study was to assess the acceptability of the intervention in participating residents. Data were collected using semi-structured interviews designed around the Theoretical Framework of Acceptability. Thematic analysis was undertaken using a general inductive approach. Of the 199 participants in the intervention arm of the original RCT, 27 were invited to take part in this qualitative study. Fifteen participants were recruited with a median age of 89 years, 10 were female and all were of European ethnicity. Participants were generally positive about the intervention and research processes. Three themes were identified: (1) participants' understanding of intervention aims and effectiveness; (2) the importance of older adult involvement and (3) level of comfort in the research process. Despite the MD intervention being deemed acceptable across several domains, results provided learning points for the future design of MD interventions in RV residents and older adults more generally. We recommend that future intervention studies incorporate co-design methodologies which may improve the likelihood of intervention success.

Vulnerable, recalcitrant and resilient: a Foucauldian discourse analysis of risk and older people within the context of COVID-19 news media

Risk is an innate and integral part of everyday life and is present in simple, everyday occupations and complex actions. Age-related stereotypes can mean older people have little opportunity to engage in activities that present some degree of risk. The present study explores the discourse around risk and older people in the context of the COVID-19 pandemic. We investigated news media as a reflection of the dominant public discourse around older people's behaviour to identify how risk is represented in relation to occupational engagement. Texts relating to older people and COVID-19 were sourced from the West Australian newspaper for a period of two months. Seventy texts were subject to Foucauldian discourse analysis to identify subject positions, location of risk and discursive features. Findings indicate that older people were segregated from the rest of society, with their behaviours framed in mostly negative ways. We identified three areas of discourse: vulnerable, and in need of protection; recalcitrant, and in need of management; and resilient, deserving of respect. While we recognise competing representations, implicit within the dominant discourse was the premise that older people were not capable of mediating risks and required ‘management’. These findings highlight the role of surveillance in restricting occupational engagement for older people and carry implications for older people, the public and therapists.

Supporting residential aged care through a Community of Practice

Transfers to Emergency Departments and hospitalizations are common for older people living in residential aged care who experience acute deterioration. This paper shares reflections from 10 years of work across a region in New South Wales, Australia, to develop a new model of care in141 residential aged care homes. The model successfully reduced Emergency Department transfers and admissions to hospital. Using an exemplar patient case, the paper describes the Aged Care Emergency Program and associated research outputs. An interprofessional, multi-agency Community of Practice supported this work. The authors reflect on the successes and challenges of using a Community of Practice to implement the model of care. We conclude that the Community of Practice, with its iterative evaluation, facilitated change and provided a mechanism for interprofessional practice. Broader systemic change requires clarity in goals of care, shared decision-making, working across sectors, and appropriate resource allocation. This article is protected by copyright. All rights reserved.

Substance use and misuse of older adults living in residential care facilities: a scoping review from a person-centred care approach

Person-centred care (PCC) in residential care facilities (RCFs) is valuable but creates challenges for care professionals balancing involvement and a partnership approach for residents while considering the health and safety outcomes of all residents. This review evaluates what is known about the substance use and misuse of residents living in RCFs and what is important to study in future research to enhance PCC, especially in cases in which residents wish to choose unhealthy behaviours. A scoping review was conducted and exclusion criteria were set. The included papers were assessed on methodological quality using the Mixed Methods Appraisal Tool and the results were qualitatively analysed. The included papers consisted of studies regarding alcohol, tobacco and illicit drugs. The results showed that care professionals are involved in facilitating and regulating alcohol and tobacco. The focus of the included papers is on alcohol and tobacco. Five of the 16 papers assessed the residents’ perspective. This review highlights the importance of incorporating the perspectives of residents, care professionals and the organisation to enhance PCC and enable residents to make shared and well-informed decisions in dialogue with care professionals. Future research should also assess the distinction between substance use and misuse, and how this affects implementing PCC in RCFs.

Bullying in physical education of children and youth with visual impairments: A systematic review

Bullying is prevalent in youth but occurs at a higher rate of incidence in children with visual impairments in comparison to children without disabilities. The purpose of this study was to conduct a systematic review of literature from the past 20 years on bullying research in physical education of youth with visual impairments. This review examined studies on bullying in physical education for school-age children with visual impairments. Articles that did not include children with visual impairments or blindness, physical education, or any type of intentional bullying were eliminated. After a thorough screening of the articles obtained in the search, 14 were selected and analyzed thematically. Results revealed that of the 114 participants in these studies, 86% experienced social–relational bullying, 64% experienced verbal bullying, and 21% experienced physical bullying. Children with visual impairments were bullied in physical education class by their teachers (50%), paraeducators (7%), and their peers (93%). The bullying occurred in class (93%), in the locker room (21%), and at various locations outside of class. Generalization of these findings to all children with visual impairments is limited due to a lack of quantitative studies found with our search criteria. However, the findings indicate a need to educate teachers and paraeducators about proper modifications to class structure and assessment practices, as well as variations to sports and physical activity, to reduce bullying. In addition, teaching self-advocacy to children with visual impairments may minimize bullying and help with peer acceptance and support in the classroom.

Attitudes towards dignity of risk in older people: A survey following a short narrative film

OBJECTIVE

To evaluate aged care staff's 'willingness to help an older person with risk-taking activities' that improve quality of life ('dignity of risk').

METHODS

Opportunity-based cross-sectional anonymous electronic survey in four Australian jurisdictions, conducted immediately after screening a short animated narrative film describing 'dignity of risk'. Survey comprised nine questions including respondent demographics, professional role, risk-taking and outcome.

RESULTS

From 24 separate screenings, there were 929 respondents. Agreement to 'help an older person with risk-taking activities' was associated with respondent prediction of the least severe harm occurring (OR = 2.22 [1.20, 4.12], P = .001). Conversely, respondents in non-executive, non-managerial roles-that is, nurses and care workers-were unlikely to agree to help with risk-taking activities (OR 0.36-0.49, P ≤ .03). There was not an association with respondent's age grouping (P = .6).

CONCLUSION

Staff self-reported attitudes towards dignity of risk are important to understand to enhance in an older person's quality of life.

Lifetime Active Care: A qualitative study of long-term family carers of people with spinal cord injury in Australia

This study reports the findings of a qualitative, grounded theory study which explored the experiences of partners and other long-term family carers living with and supporting loved ones with spinal cord injury. The study is exploratory in that little was previously known about the experience of long-term care-giving in this context in Australia. Most research in this area has focused on this experience during the first 5 years postinjury. This study focuses on the experiences of family carers beyond that 5-year period. The study aimed to explore the experience of partners and other long-term family carers of people with spinal cord injury, and illuminate their daily lives, interests, concerns and caring approaches in this context. Data collection included in-depth interviews, a focus group and an on-line, password-protected research blog for participant narrative reflections. Findings revealed that the experience of long-term caring is complex, all-encompassing and lifelong. This experience is conceptualised here as lifetime active care which always involves what we describe as protective, negotiated, surreptitious and strategic caring. These dimensions of caring are interdependent and deeply embedded in the daily, active support provided by long-term carers of people with spinal cord injury. We argue that carers in this context are involved in processes that have, in other contexts, been conceptualised as narrative reconstruction and also that the four dimensions of caring identified involve significant emotion work. The social processes of lifetime active care may shed light on the experiences of family carers in other long-term care contexts.

Green spaces, dementia and a meaningful life in the community: A mixed studies review

Engagement in green spaces impacts positively on wellbeing and quality of life. However, little is known about the impacts of green space engagement specifically for people living with the experience of dementia in the community; people with a heightened need to maintain a quality life. In this mixed study review, we explore existing evidence for quality of life impacts of contact with green spaces by people living with dementia in the community. Findings show that gardens and horticultural programs, green care farms, parks, urban woodlands and neighbourhood outdoor environments can impact positively in several ways. Four key mechanisms are identified: Engaging in meaningful activities; Empowerment; Positive risk taking; and Reinforcing Identity. These findings provide conceptual links between psychosocial understandings of the relationships between nature and wellbeing with rights-based dementia discourses. We conclude that evidence specific for people living with dementia in the community setting is growing and there is potential for green spaces to enable an active and meaningful community-life, despite cognitive decline. This is worthy of consideration by policy makers, practitioners and carers. Future studies can broaden this field of research and include investigations into lesser-explored aspects of quality of life, such as spirituality, and methods that incorporate the voices of people living with dementia.

Conceptualising trust in aged care

This article calls for a sociological understanding of the importance of trust to aged care. It connects existing theories of trust to empirical evidence from gerontology and nursing research. Trust is defined as a response to and management of social vulnerability. It is argued this makes trust a fundamental concept for understanding human service and social care institutions, including aged care. In light of Australia's Royal Commission into Aged Care Quality and Safety, as well as generational shifts in consumer expectations and care ethics, the article highlights four distinct yet interrelated forms of trust: interpersonal, institutional, organisational and public trust. All of these forms are shown to be critical in conceptualising and evaluating the perceived trust deficit facing contemporary aged-care systems, and existing evidence shows how these forms of trust can reinforce, conflict and misalign with each other. Efforts to rebuild trust in aged care at an organisational and institutional level should ensure mechanisms facilitate rather than hinder the formation of interpersonal trust relations between individual service users, their families and aged care staff. Broader social policy reforms must also consider and address the way cultural understandings of ageing, and media representations of aged care, have diminished the public's trust in the sector, and how the cycle of scandals, reviews and piecemeal reforms contributes to this.

Applying dignity of risk principles to improve quality of life for vulnerable persons

OBJECTIVES

Freedom of choice impacts quality of life. Expressed through dignity of risk (DoR), nursing home (NH) residents should be afforded the dignity to take risks to enhance well-being. How DoR is understood and implemented in the context of aged care remains largely unknown. This study explored the meaning and the barriers and facilitators to applying DoR to NH residents.

METHODS

Qualitative study, comprising semistructured interviews. Senior policy makers and advocate guardians working in the aged care or disability sector were invited to participate. Recruitment continued until data saturation was reached. Two researchers coded interviews, applying inductive and thematic analysis.

RESULTS

Fourteen participants took part during 2016-2017. Analysis demonstrated uniformity in participants' description of DoR, comprising four elements: (a) individuals are at the centre of decision making; (b) life involves risk; (c) individuals must have choice; and (d) DoR is a continuum of experiences. Three main barriers for implementing DoR into practice were identified: (a) balancing autonomy with risks; (b) situational nature of DoR; and (c) taking responsibility for risk.

CONCLUSION

The novel findings provide an explicit understanding of DoR and the facilitators and barriers to applying the principle in the NH setting. These findings inform those who engage in making and implementing choices in the presence of risk for vulnerable clients. To translate the multifaceted elements of DoR into practice requires the development of unambiguous policies/guidelines about who will be responsibility for potential risks that may arise from residents' choices. Further, education programmes supporting care staff/management to enact resident choices in the presence of real or perceived risk are required.

Inclusive Decision Making for Falls Prevention: A Discussion Tool for Use With People With Dementia and Their Caregivers

Provision of choice and participation in falls prevention strategies is challenging for people with dementia. This study outlines development of a discussion tool to aid engagement of people with dementia and their caregivers in falls prevention strategies. The tool is based on a literature review of falls prevention and dementia care (1990-2016) and decision aid principles and was trialed over 6 months. A total of 25 community-dwelling people with dementia (M_age = 80 years, SD = 7.7, 52% male) and their caregivers (M_age = 73 years, SD = 12.3, 36% male) underwent falls risk assessment and evaluation of their preparedness to change falls risk behaviors. Most commonly rated, and prioritized for intervention, high falls risk factors were impaired balance/mobility (92%), polypharmacy (60%), and incontinence (56%). This discussion tool facilitated collaboration between people with dementia, their caregivers, and health professionals, to increase uptake of acceptable and feasible evidence-based falls prevention strategies.

Recommendations for the prevention of deaths among nursing home residents with unexplained absences

OBJECTIVES

Unexplained absences (UAs) contribute to the mortality and morbidity rates in the nursing home (NH) population. Valuing expert professional knowledge and skills is central to the achievement of improved care in NHs. This study developed and prioritised recommendations to prevent deaths of NH residents (NHRs) with UAs.

METHODS

Two expert consultation forums using the modified nominal group technique to develop recommendations were conducted, followed by an online survey to prioritise the most important recommendations for implementation. A framework applying the temporal dimension ("pre-event," "event" and "post-event") of an internationally accepted injury prevention framework, Haddon's Matrix, was applied to the recommendations. Participants were purposively sampled and identified via aged care organisations; and were selected based on their experience in aged care practice, policy, research, elder rights, seniors' law, or missing persons search and rescue (SAR).

RESULTS

Forum one comprised six, and forum two comprised nine experts from mixed disciplines. Seven participants completed the online survey. Twenty recommendations to prevent future injury and death were developed, five of which were prioritised for implementation in the aged care sector. In order of priority, these include: universal UA definition; mandated SAR plan, early assessment of NHRs; unmet needs behavioural assessments; and participation in decision-making.

CONCLUSIONS

The recommendations cover the broad spectrum of complex issues raised in managing unexplained absences, and are a vital first step towards informing care providers, governments and SAR teams about how to prevent injury and death of NHRs in residents with UAs. Future research should explore how to translate and evaluate the recommendations into practice.

Deaths due to thermal injury from cigarette smoking in a 13-year national cohort of nursing home residents

OBJECTIVES

To examine the nature and frequency of deaths due to thermal injuries from cigarette smoking reported to Australian coroners and to examine the decisions which surround these deaths.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents dwelling in accredited nursing homes whose deaths were reported to coroners between 1 July 2000 and 30 June 2013 and attributed to thermal injuries from cigarette smoking.

MEASURES

A descriptive analysis was undertaken to report socio-demographic characteristics of the deceased, medical history, mobility, level of observation, safety equipment provided/used, nursing home location, decision to smoke, timing of incident, time from incident to death, incident findings, mechanism of death, formal reports attached and coroners' recommendations.

RESULTS

Ten deaths of nursing home residents due to thermal injury from cigarette smoking were reported in Australia over a 13-year period. The median age of residents was 78 years (IQR = 15.25); nine residents were female and one was male. Seven residents had impaired mobility with three residents being wheelchair bound and one resident bed bound. None of the residents were supervised by staff while they smoked, and none of the residents utilised any safety equipment to minimise harm. Burns/thermal injury was the mechanism of harm in most cases.

CONCLUSIONS

This national study confirms that thermal injuries caused by cigarette smoking in nursing homes result in fatalities, particularly in the absence of supervision. It also demonstrates the complex tension arising from balancing autonomy with safety.

IMPLICATIONS FOR PRACTICE

Nurses and aged care practitioners should endeavour to give effect to each resident's wishes while mitigating the risk of harm. The supervision requirements for cigarette smoking residents should be tailored to the needs of individual residents and staff should try to ensure that residents who require supervision receive it.

Managing risk for aging patients in long-term care: a narrative review of practices to support communication, documentation, and safe patient care practices

Resident safety and welfare in long-term care (LTC) is being redefined as the focus shifts to promoting an optimal quality of life especially in LTC. Achieving this requires contemporary practice to improve the organization and staff’s ability in identifying, communicating, documenting, and managing the risks that arise from the choices a person makes in pursuit of a better quality of life. This article is a narrative realist style review examining the issues of how to manage risks for older residents living in LTC. The issues are examined in six stages: context, identifying, communicating, documenting, enacting, reviewing and reflecting on how choices are made and risks managed. It is important for individuals to be supported in making an informed choice – this requires identifying, providing, and communicating the available options and the potential consequences. Documenting consent, perhaps with formal risk agreements, provides clarity for all involved and assists in determining how and who is responsible for enacting choices. Reviewing and reflecting upon the decisions and actions to enact choices are familiar to prudent LTC managers who implement and monitor robust governance systems. Learning from these experiences is essential to better meet individual resident, staff, organizational, and community expectations. Improving practice at each of the six steps should reduce adverse professional and legal repercussions and enable the resident, families, and staff to better cope with respecting choices when a known harmful outcome eventuates.

The landscape of dementia inclusivity

A supported community gardening program became appealing and therapeutically beneficial to people living with the impacts of dementia and their carers, despite not targeting either cohort specifically. This paper discusses how this program provides insights into the landscape of dementia inclusivity. The gardens involved were spaces that allowed positive risk-taking opportunities, respectful intersubjectivity and active citizenship. Our research findings indicate that a meaningful response to the rising incidence of dementia may be to build upon social and geographical attributes of community gardens. Understanding the multifaceted nature of a dementia inclusive landscape will enable authentic engagement and rights-based support for people living with the impacts of dementia.

Cultural Competency in Dementia Care: An African American Case Study

Age is the greatest risk factor for Alzheimer's disease, the most common cause of dementia. The older population in the United States is growing, and within this demographic ethnic and racial diversity is also on the rise. This article introduces Stanford Health Care's Memory Support Program (MSP) as a model for culturally competent dementia care that spans inpatient and outpatient settings. The case study of an African American patient and family dealing with an Alzheimer's disease diagnosis and comorbid conditions is presented and explored to illustrate the MSP model. The authors make recommendations for the implementation of similar continuum of care services in other institutions. As research continues to show, the cultural competence of medical professionals can impact patient quality of care and health outcomes. More research is needed to appropriately support positive outcomes for patients and families of diverse ethnic and racial backgrounds.

Development of a discussion tool to enable well-being by providing choices for people with dementia: a qualitative study incorporating codesign and participatory action research

OBJECTIVE

To codesign a discussion tool to facilitate negotiation of risk between health professionals, people with dementia and carers.

METHODS

A qualitative approach using codesign. Thematic analysis was used to analyse interviews and focus groups with people with dementia, carers, healthcare staff and healthy older people exploring the issue of risk in dementia, the acceptability and development of a discussion tool.

RESULTS

Sixty-one participants identified the breadth, depth and complexity of risk in dementia care and the need for individualised solutions. They also deemed a discussion tool to facilitate negotiation of risk was acceptable and responses informed the tool development. Twenty-two participants provided feedback that was used to refine the final version.

CONCLUSION

Our discussion tool enables choices for people with dementia by focusing on abilities rather than deficits and assists health professionals to deliver person-centred care. Flash cards prompt concerns and the tool provides a range of strategies to address these issues.

'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.

Premature and preventable deaths in frail, older people: a new perspective

The concept and potential implications of a premature death of an older person are under-recognised and misunderstood by society. Clinical, forensic and public health practitioners need to redress this gap to prepare society better for a future where an increasing proportion of the population are vulnerable older people. Reliable and valid information is paramount for understanding how many older people have premature, preventable deaths, with implications for aged care services, health-care expenditure, quality and safety, and human rights. Our aim is to: (a) provide discourse on the limitations and challenges to the use of the concepts ‘premature’ and ‘preventable’ deaths, examining the situation for nursing home residents; and (b) propose the use of a novel classification system of ‘treated’, ‘un-treated’ and ‘untreatable’ causes of death that is more sophisticated and reflects the demographic reality of our ageing population. Accepting that preventable, premature deaths may happen to older people and adopting a new classification is a novel approach that has considerable benefits for health and life care of older persons. Improved assessment of the quality of care provided, including identification of health or life care practices that are unsafe or deleterious, can be identified and addressed.

Dignity in long-term care: An application of Nordenfelt's work

BACKGROUND

The concept of dignity is recognised as a fundamental right in many countries. It is embedded into law, human rights legislation and is often visible in organisations' philosophy of care, particularly in aged care. Yet, many authors describe difficulties in defining dignity and how it can be preserved for people living in long term care.

OBJECTIVES

In this article, Nordenfelt's 'four notions of dignity' are considered, drawing on research literature addressing the different perspectives of those who receive, observe or deliver care in the context of the long-term care environment.

METHODS

A review of the literature was undertaken using the terms 'nursing homes', 'residential care' or 'long-term care'. The terms were combined and the term 'human dignity' was added. A total of 29 articles met the inclusion criteria from the United Kingdom (14), United States (2), Australia (1), Sweden (3), Hong Kong (2), Norway (3), Nordic (1), Taiwan (1), Netherlands (1). Ethical Considerations: Every effort has been made to ensure an unbiased search of the literature with the intention of an accurate interpretation of findings.

DISCUSSION

The four notions of dignity outlined by Nordenfelt provide a comprehensive description of the concept of dignity which can be linked to the experiences of people living in long-term care today and provide a useful means of contextualising the experiences of older people, their families and significant others and also of staff in long-term care facilities. Of particular interest are the similarities of perspectives of dignity between these groups. The preservation of dignity implies that dignity is a quality inherent in us all. This links directly to the exploration and conclusions drawn from the literature review. Conversely, promoting dignity implies that dignity is something that can be influenced by others and external factors. Hence, there are a number of implications for practice.

CONCLUSION

We suggest that two of Nordenfelt's notions, 'dignity of identity' and 'dignity of Menschenwüde', are a common thread for residents, family members and staff when conceptualising dignity within long-term care environments.

Nature and extent of external-cause deaths of nursing home residents in Victoria, Australia

OBJECTIVES

To describe the nature and extent of external-cause deaths of residents of nursing homes in Victoria, Australia.

DESIGN

A retrospective cohort study of all decedents using routinely collected data contained within the National Coronial Information System.

SETTING

Accredited nursing homes in Victoria.

PARTICIPANTS

Nursing home residents who had died from external causes and whose deaths were reported to the Coroners Court between July 1, 2000, and December 31, 2012.

MEASUREMENTS

Basic descriptive analysis was conducted to measure frequencies and proportion of exposures within each outcome group, and rates were calculated using population data.

RESULTS

One thousand two hundred ninety-six external cause deaths of nursing home residents were identified. Deaths were due to falls (n=1,155, 89.1%), choking (n=89, 6.9%), suicide (n=17, 1.3%), complications of clinical care (n=8, 0.6%) and resident-on-resident assault (n=7, 0.5%). Deaths occurred more frequently in women (n=814, 62.8%), in keeping with the sex distribution in nursing homes, and residents aged 85 and older (n=923, 71.2%). The number of inquests held to investigate a death as a matter of public interest was small (n=24, 1.9%).

CONCLUSION

A significant proportion of nursing home resident deaths are from external causes and are potentially preventable. A shift in community attitudes is required toward an understanding that premature death of a resident from injury is not a natural part of life.