Risk and ageing populations: practice development research through an international research network

Risk-taking behaviors and falls in community-dwelling older adults: a scoping review protocol

OBJECTIVE

The objectives of this proposed scoping review are to systematically identify the risk-taking behaviors in community-dwelling older adults as well as the methods used to identify these behaviors. This review explores predisposing factors to fall-related, risk-taking behaviors in community-dwelling older adults.

INTRODUCTION

Most falls occur as a result of complex interactions between fall risk factors. Research has identified the role of mobility and environmental factors in falls; however, little is known about the role of risk-taking behaviors on falls.

INCLUSION CRITERIA

Studies that explore fall-related, risk-taking behaviors in community-dwelling older adults (≥65 years) will be included for this review. Studies will be considered if they are conducted in a research laboratory or community-based setting. Hospital settings will be considered if the study discusses risk-taking in community-based settings.

METHODS

A comprehensive literature search will be completed in Ovid AMED, Ovid Embase, Ovid MEDLINE, Ovid PsycINFO, EBSCOhost CINAHL and EBSCOhost AgeLine. Only studies published from the year 2000 onward will be considered for inclusion. Studies published in English and French will be considered for inclusion. Two reviewers will independently screen titles and abstracts to identify studies for full review. The full texts will then be independently reviewed by the same reviewers to assess eligibility, with a third reviewer available to resolve disagreements. A data extraction tool will be used to extract the data from the studies that meet full eligibility criteria. Data extracted from the texts will be synthesized and reported in table format accompanied by a narrative summary that will connect the results the objective of the scoping review.

SCOPING REVIEW REGISTRATION

Open Science Framework: https://osf.io/r9f7v.

Pervasive Risk Avoidance: Nursing Staff Perceptions of Risk in Person-Centered Care Delivery

BACKGROUND AND OBJECTIVES

Nursing home (NH) staff perceptions of risks to residents' health and safety are a major barrier to honoring resident preferences, the cornerstone of person-centered care (PCC) delivery. This study explored direct-care nursing staff perceptions of risk (possibilities for harm or loss) associated with honoring residents' preferences for everyday living and care activities.

RESEARCH DESIGN AND METHODS

Qualitative, descriptive design using sequential focus group (FG) methodology.

RESULTS

Participants (N = 27) were mostly female (85%), had more than 3 years of experience (74%), and worked in NHs recently experiencing 6-12 health citations. Content analysis of 12 sequential FGs indicated nursing staff perceptions of risks may impede delivery of person-centered care. This is supported by the overarching theme: pervasive risk avoidance; and subthemes of: staff values, supports for risk-taking, and challenges to honoring preferences.

DISCUSSION AND IMPLICATIONS

Development of a multidimensional framework with specific risk engagement measures that account for the unique risk perspectives of nursing staff will contribute significantly to the clinical management of older adult preferences and research on the effectiveness of preference-based PCC delivery in the NH setting.

Stress as Experienced by People with Dementia: An Interpretative Phenomenological Analysis

Health and social care research on stress in dementia has predominantly considered the stress experienced by family and professional carers. Focus on the person with dementia has frequently laid emphasis on the impact of stress-related behaviour on others and how such behaviour might be 'managed'. This paper describes a qualitative study which gives voice to people with dementia on the subject of stress and responds to the need for a better understanding of stress as it is experienced by people with dementia themselves. An interpretative phenomenological analysis was conducted on data collected from a purposive sample of people diagnosed with varying types of dementia from across Scotland. Discussions across five focus groups consisting of 21 participants with dementia in total generated data which was audio and video recorded, and analysed thematically. Five key themes emerged, described in the participants' own words, which were: (1) 'Something's torn, your life's torn'; (2) 'Families can bring stress'; (3) 'It's the stress of living with dementia'; (4) 'A whole new set of rules'; and (5) 'It's our lives and we'll get it under control ourselves'. These themes reflect experiences of loss, challenges to one's sense of self, relationship dynamics, living with the symptoms of dementia, learning to do things differently and establishing coping mechanisms that provide control. Study participants illustrated individual potential for adapting and coping with some of the most stressful aspects of living with dementia, challenging assumptions of inevitable fixed decline and progressive vulnerability to stress. Participants describe a process of recovery in their perceptions of self-worth, purpose and value in life following diagnosis.

Risks and older adults with atrial fibrillation in rural communities: an integration lens

Purpose

– Older adults with atrial fibrillation (AF) have put growing demands on a poorly integrated healthcare system. This is of particular concern in rural communities with rapid population aging and few healthcare resources elevating risk of stroke and mortality. The purpose of this paper is to explore healthcare delivery risks for rural older adults with AF.

Design/methodology/approach

– This qualitative study collected data from AF patients, healthcare providers and decision makers. Ten patients participated in six-month care journeys involving interviews, logs, photos, and chart reviews. In total, 13 different patients and ten healthcare providers participated in focus groups and two decision makers participated in interviews.

Findings

– Three key health service risks emerged: lack of patient-focussed access and self-management; unplanned care coordination and follow-up across the continuum of care; and ineffective teamwork with variable perspectives among patients, providers, and decision makers.

Originality/value

– This study extends the understanding of risks to the health system level. Results provide important information for further research aimed at interventions to improve health service delivery and policy change to mitigate risks for this population.

Re-finding the 'human side' of human factors in nursing: helping student nurses to combine person-centred care with the rigours of patient safety

In this paper the authors explore the centrality of both patient safety and person-centred care when preparing student nurses for their role. By examining these two goals against the understanding of human factors, the concept of risk and the interpersonal elements of patient centred, compassionate care, the authors identify the challenges that nurse educators must recognise in preparing the nurses of the future who must achieve both. The authors introduce the notion of human factors and their role in promoting safe environments. Thereafter the authors explore the development of the student nurse in coming to understand that optimal patient care must primarily be safe but must also have the wishes of individual patients at its core. Finally the authors raise the challenge for nurse educators of supporting students' growing understanding of safety, risk and how these must be balanced with individual needs and wishes.

Enacting Fall Prevention in Community Outreach Care

Despite increased international concern about fall prevention throughout the past 20 years, only limited attention has been paid to the experiences and perspectives of health care providers who deliver fall prevention programs. The purpose of this interpretive phenomenological study was to explore the meaning of the experience of enacting fall prevention, through individual semistructured interviews, among 6 members of an interprofessional geriatric outreach team in Ontario, Canada. Findings suggest that enacting careful practice was essential to the experience of enacting fall prevention, represented by four interrelated phenomenological themes: caring fully for older clients, carefully seeing older clients in their life contexts, enacting therapeutic relationships, and experiential learning in interprofessional teams. We discuss findings in relation to literature on emotional labor, leading to suggestions for the policy and practice of fall prevention.

The language of risk: common understanding or diverse perspectives?

Risk as a concept now takes high priority in contemporary mental health services, with increasing pressure on mental health services to develop risk assessment and management practices. This focus on risk has been criticised for its over-reliance on measurement and management at the expense of therapeutic care and is perpetuated by the language of risk which reinforces power differentials and limits capacity for consumers and carers to influence discussions and debates. Furthermore, to date, most work in this area reflects adult settings with limited consideration of the unique needs of older people and the impact of risk assessment on the care they receive. A qualitative, exploratory approach was undertaken using individual interviews and focus groups to enhance understanding of how risk is conceptualised within an older persons' setting. Managers, clinicians, consumers, and carers from a large metropolitan service participated (n = 57). The language of risk was a major theme emerging from this work. This language, so familiar to providers of services, was not familiar to consumers and carers. A reframing of risk is necessary to reflect consumers' and carers' experiences and understandings. This approach will be essential in promoting consumer and carer participation within recovery-based services, reflecting significant goals of government policy.

Rethinking 'risk' and self-management for chronic illness

Self-management for chronic illness is a current high profile UK healthcare policy. Policy and clinical recommendations relating to chronic illnesses are framed within a language of lifestyle risk management. This article argues the enactment of risk within current UK self-management policy is intimately related to neo-liberal ideology and is geared towards population governance. The approach that dominates policy perspectives to 'risk' management is critiqued for positioning people as rational subjects who calculate risk probabilities and act upon them. Furthermore this perspective fails to understand the lay person's construction and enactment of risk, their agenda and contextual needs when living with chronic illness. Of everyday relevance to lay people is the management of risk and uncertainty relating to social roles and obligations, the emotions involved when encountering the risk and uncertainty in chronic illness, and the challenges posed by social structural factors and social environments that have to be managed. Thus, clinical enactments of self-management policy would benefit from taking a more holistic view to patient need and seek to avoid solely communicating lifestyle risk factors to be self-managed.

Reframing risk management in dementia care through collaborative learning

Risk management is a complex aspect of practice which can lead to an emphasis on maintaining physical safety, which impacts on the well-being of people with dementia. Education for practitioners in risk management is particularly challenging because of its conceptual nature and diverse perceptions of risk between and within professional groups. The practice development research reported here formed one part of a multisite study and contributed to developing a risk assessment and management framework for use by practitioners in partnership with people with dementia and their families. Practice development research uses learning theories in the process of the research, and in so doing its intent is to not only create new knowledge but to view the research process as also a process of learning for those involved. Twenty practitioners from varying professions participated in five Collaborative Learning Groups, each of at least 2 hours duration, which were held over a 7-month period. Data analysis highlighted contradictions in the care system and in the professional's intention to practice in a person-centred way. These were expressed through the themes of: Seeking Certainty; Making Judgements; Team Working; Managing Complexity; Gathering and Using Information.

A cooperative inquiry into action learning and praxis development in a community nursing module

As nurse lecturers we investigated practice development and action learning approaches aimed at enabling postregistration bachelor's- and master's-level nursing students (Community Health Studies, Nursing in the Home) to advance practice in the context of policy and professional developments. A patchwork text was used to assess summatively what students achieved (practice change/development) and how this was informed critically, via an extended epistemology. First-person inquiry supplemented by cooperative inquiry postcourse completion (including reflective discussions with 16 students and 16 practice mentors) were used to assist coresearcher constructions of meaning. A relational, tripartite approach to learning and assessment (students', teachers', and practice mentors' collective contributions) depends on continuing reflective attention. Action learning enhances interrelation of experience with dialectic thinking. The patchwork text functions to promote creative writing, evaluative thinking, and praxis development. Role modeling by all, being genuine and not just "talking" genuine, is challenging yet crucial if people are to function as mutual resources for learning.

Patchwork text: a praxis oriented means of assessment in district nurse education

A patchwork text was used to assess summatively B.Sc. and M.Sc. district nurse students' learning and how this was informed critically, during a module on a one year fulltime community programme. Assessment was embedded within an action learning process that adopted an extended epistemology so students demonstrated connections between practice, theory and their reflections. Five lecturers undertook first-person and co-operative inquiry into their experiences, including post-course reflexive discussions with 16 students and their practice mentors. Maintaining reflective diaries functioned to enhance writing as learning, with students presenting in non-linear terms, their regress, progress and self-evaluative skills. Marking was challenging for lecturers. Elements of criteria based upon portfolio assessment and qualitative research were supplemented by action research quality indicators, in terms of students explicating their choices and rationale. Summative judgements were enhanced and validated by markers engaging in critical dialogue with second markers and moderators and not through exclusive use of ever-increasingly sophisticated criteria. Crucially, assessment requires mentor verification of students' accounts. In summary, a relational, tripartite approach to learning and assessment (students, teachers and practice mentors collective contributions) enhances quality of both learning and its assessment, including competency assessment. Errors and weaknesses are also identified, no panaceas are claimed.