Person-centered dementia care in home care services - highly recommended but still challenging to obtain: a qualitative interview study

How do the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home? A qualitative interview study with multiple stakeholders

Introduction

Often, homecare services are task-focused rather than person-based and fragmented instead of integrated. Consequently, several stakeholders have requested a transformation of the service ecosystem for senior citizens living at home. This transformation may be facilitated by an idealized design approach. However, few studies have applied such an approach. Moreover, previous research did not assess the ways in which the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home. Therefore, the purpose of this study is to gain an understanding of how the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home, according to different stakeholders.

Methods

Four stakeholder groups (n = 57) from a Norwegian municipality participated in an interview study (2019-2020): senior citizens, carers, healthcare professionals and managers. A directed qualitative content analysis was applied, guided by a four-category framework for the preferred service ecosystem.

Results

All stakeholder groups highlighted several limitations that hindered continuity of the services. There was also agreement on deficiencies in professionals' competence, yet professionals themselves did not focus on this as a significant aspect. Managers emphasised the importance of professionals' reablement competence, which was also considered to be deficient in the current homecare services. Contrary to the other stakeholder groups, most senior citizens seemed satisfied with the practical and social support they received. Together with carers, they also explained why they thought some professionals lack compassion. Their dependency on professionals may limit them in sharing honestly their opinions and preferences during care provision. Involvement of senior citizens in improvement of the current services was limited. Insufficient time and resources, as well as a complex organisation impacted the existing homecare services, and therefore served as barriers to the preferred service ecosystem.

Discussion

In this study there were different degrees of correspondence between the existing homecare services and the preferred service ecosystem according to four stakeholder groups. To develop the preferred service ecosystem, aspects such as predictability, adaptivity, and relationships are key, as well as continuous involvement of senior citizens and other stakeholders. The four-category framework applied in this study served as a tool to assess the existing homecare services.

Co-design of the EMBED-Care Framework as an intervention to enhance shared decision-making for people affected by dementia and practitioners, comprising holistic assessment, linked with clinical decision support tools: A qualitative study

INTRODUCTION

Shared decision-making intends to align care provision with individuals' preferences. However, the involvement of people living with dementia in decision-making about their care varies. We aimed to co-design the EMBED-Care Framework, to enhance shared decision-making between people affected by dementia and practitioners.

METHODS

A theory and evidence driven co-design study was conducted, using iterative workshops, informed by a theoretical model of shared decision-making and the EMBED-Care Framework (the intervention) for person-centred holistic palliative dementia care. The intervention incorporates a holistic outcome measure for assessment and review, linked with clinical decision-support tools to support shared decision-making. We drew on the Medical Research Council (MRC) guidance for developing and evaluating complex interventions. Participants included people with dementia of any type, current or bereaved family carers and practitioners. We recruited via established dementia groups and research and clinical networks. Data were analysed using reflexive thematic analysis to explore how and when the intervention could enhance communication and shared decision-making, and the requirements for use, presented as a logic model.

RESULTS

Five co-design workshops were undertaken with participants comprising people affected by dementia (n = 18) and practitioners (n = 36). Three themes were generated, comprising: (1) 'knowing the person and personalisation of care', involving the person with dementia and/or family carer identifying the needs of the person using a holistic assessment. (2) 'engaging and considering the perspectives of all involved in decision-making' required listening to the person and the family to understand their priorities, and to manage multiple preferences. (3) 'Training and support activities' to use the Framework through use of animated videos to convey information, such as to understand the outcome measure used to assess symptoms.

CONCLUSIONS

The intervention developed sought to enhance shared decision-making with individuals affected by dementia and practitioners, through increased shared knowledge of individual priorities and choices for care and treatment. The workshops generated understanding to manage disagreements in determining priorities. Practitioners require face-to-face training on the intervention, and on communication to manage sensitive conversations about symptoms, care and treatment with individuals and their family. The findings informed the construction of a logic model to illustrate how the intervention is intended to work.

Older adults' experiences of self-determination when needing homecare services-an interview study

BACKGROUND

Self-determination has been shown to be an important factor in mental health and wellbeing, but from the homecare recipients' point of view, autonomy and self-determination is not fully integrated into homecare services. The aim of this study was to explore older adults' experiences of self-determination when needing homecare services.

METHODS

In 2018, a qualitative descriptive study was conducted and a convenience sample of 15 older adults from 3 homecare service facilities were invited to participate in individual interviews. Data were analysed using qualitative content analyse.

RESULTS

The theme Transitioning from self-determination as independence towards self-determination as shared decision-making emerged through the older adults' narratives. This 'transition' is one in which older adult's understanding of self-determination and self-esteem was transitioning towards the acceptance of shared decision-making. The person's inner strength and willingness to make decisions was promoting to enact and preserve independence. Accepting one's dependence on others and being in a positive atmosphere were described as promoting self-determination and shared decision-making, and vice versa. The above overarching theme permeated all subthemes, which included: mobilising inner strength to enact independence; accepting increasing dependence on others; and being influenced by the atmosphere.

CONCLUSIONS

The study contributes increased understanding of older adults' experiences of self-determination. The results can act as a guide when planning future person-centred care interventions in the context of homecare services and help improve homecare services' ability to meet the needs of older adults. To summarise, older adults' reflections on their own self-determination highlighted relationships with other people as important for shared decision-making, which could help preserve older adults' autonomy and self-esteem.

Use of adapted or modified methods with people with dementia in research: A scoping review

People with dementia are excluded from research due to methodological challenges, stigma, and discrimination. Including perspectives of people with dementia across a spectrum of abilities is essential to understanding their perspectives and experiences. Engaging people living with dementia in qualitative research can require adaptation of methods.Qualitative research is typically considered when researchers seek to understand the perspectives, lived experiences, or opinions of individuals' social reality. This scoping review explores current use of adapted methods with people with dementia in qualitative research, including methods used and impacts on the engagement as it relates to meeting accessibility needs. This review considered rationales for adaptations provided by authors, particularly whether authors identified a human rights or justice rationale for adapting methods to promote accessibility and engagement.This review began with a search of primary studies using qualitative research methods published in English in OECD countries from 2017 to 2022. Two reviewers screened titles and abstracts for inclusion. Full texts were reviewed, and data from included studies were extracted using a pre-determined chart. Content analysis of rationales was conducted and reviewed by all authors. Studies were assessed for findings related to impacts of adapted methods.Twenty-eight studies met inclusion criteria. Adaptations to qualitative research methods ranged from minor changes, such as maintaining a familiar interviewer, to more extensive novel methods such as photo-elicitation techniques. Twenty-seven studies provided a rationale for adapting their methods. No studies assessed impacts of their methodology on engagement or accessibility. Five studies observed that their methodology supported engagement.This review helps understand the breadth of adaptations that researchers have made to qualitative research methods to include people with dementia in research. Research is needed to explore adaptations and their impact on engagement of persons with dementia with a range of abilities and backgrounds.

Experiences of older people, healthcare providers and caregivers on implementing person-centered care for community-dwelling older people: a systematic review and qualitative meta-synthesis

BACKGROUND

Person-centered care (PCC) is a critical approach to improving the quality of care for community-dwelling older people. Old-age care services could be provided according to older peoples' choices, needs, and preferences. The purpose of this study was to synthesize research evidence on the experiences of older people, healthcare providers, and caregivers with PCC and to identify the enablers and barriers to implementing PCC for community-dwelling older people.

METHODS

A meta-synthesis of qualitative research design was adopted. Data searches were performed using CINAHL (EBSCOhost), PubMed (OvidSP), Embase (Ovid), Cochrane Database, and PsycINFO (Ovid) in published articles and were reviewed from the earliest date to February 2023. The Qualitative Method Appraisal Tool was used to conduct a quality appraisal on selected articles. Data were extracted based on the capacity, opportunity, and motivation-behavior model (COM-B model), and the findings were synthesized using the meta-aggregative approach.

RESULTS

Twelve included articles were analyzed to identify 122 findings that were organized into 11 categories and combined into three synthesized findings-capacities of older people, healthcare providers, and caregivers; opportunities in the implementation of PCC; motivation in implementing PCC. Capacities consisted of a lack of person-centered knowledge and skills, negative attitudes toward shared decision-making, and a lack of formal training to enhance capabilities among HCPs. Opportunities included a lack of coordination in resource allocation, strengthening multidisciplinary teamwork, establishing a desirable environment, and time constraints. Motivation in implementing PCC included encouraging self-reflection and regulation, respecting the autonomy of older people, lack of clear reward and empowerment mechanisms, and being resilient and optimistic.

CONCLUSIONS

The findings of this research provide a reference for implementing successful PCC in the community. The researchers identified barriers and facilitators of implementing PCC, facilitating through stakeholder's person-centered knowledge and skills being valued and respecting the autonomy of older people. Establishing a positive environment and strengthening multidisciplinary team members also promotes the implementation of PCC. However, additional studies are required to explore the influencing factors and address the barriers.

Self-perceived care needs and quality of life in people with cognitive impairment during routine care at home: cross-sectional results of the interventional study

BACKGROUND

Cognitive impairment (CI) is one of the most common disabling symptoms in the elderly, and people with CI face a variety of unmet care needs. There is limited evidence on the relationship between unmet needs and quality of life (QoL) of people with CI. The aim of this study is to analyse the current situation of unmet needs and QoL among people with CI, and to explore the correlation between QoL and unmet needs.

METHODS

The analyses use baseline data of the intervention trial, which recruited 378 participants to complete the questionnaire including the Camberwell Assessment of Need for the Elderly (CANE), and the Medical Outcomes Study 36-item Short-Form (SF-36). The SF-36 was further gathered into physical component summary (PCS) and mental component summary (MCS). Multiple linear regression analysis was conducted to explore the correlations between unmet care needs and PCS and MCS of SF-36.

RESULTS

The mean score of each of the eight domains of SF-36 was significantly lower than the Chinese population norm. The incidence of unmet needs ranged from 0 to 65.1%. Multiple linear regression results showed that living in rural areas (Beta=-0.16, P < 0.001), having unmet physical needs (Beta=-0.35, P < 0.001), and unmet psychological needs (Beta=-0.24, P < 0.001) were associated with lower PCS scores, whereas duration of CI > 2 years (Beta=-0.21, P < 0.001), unmet environmental needs (Beta=-0.20, P < 0.001), and unmet psychological needs (Beta=-0.15, P < 0.001) were associated with lower MCS scores.

CONCLUSION

The main results support the important view that lower QoL scores are associated with unmet needs in people with CI, depending on the domain. Given that the more unmet needs can further worsen QoL, it is recommended that more strategies should be taken, especially for those with unmet care needs, so as to improve their QoL.

Development, reliability, and validity of a self-assessment scale for dementia care management

BACKGROUND

This study aimed to develop a self-assessment scale for care management of people with dementia and examine its reliability and validity.

METHODS

Based on Bloom's Taxonomy, previous research, and experts' opinions on dementia and care management, a scale consisting of 18 items was developed to assess care managers' attitudes, knowledge, and skills in their management of people with dementia. To examine the scale's reliability and validity, data were collected from 638 care managers. Construct validity using exploratory factor analysis, known-group validity, and internal consistency reliability of the scale were evaluated.

RESULTS

Exploratory factor analysis supported the construct validity with a four-factor model and explained 59.1% of the total variance. Following were the four factors: Factor I 'Person centred care'; Factor II 'Understanding of disease characteristics, treatment and care'; Factor III 'Understanding of people with dementia and care management according to their characteristics'; and Factor IV 'Utilization of local resources surrounding people with dementia'. Regarding the known-group validity, results showed that the group with a qualified chief care manager scored significantly higher than the group without one on Factors I (P = 0.013) and III (P = 0.026). Cronbach's alpha coefficient for the 18 items was 0.928.

CONCLUSIONS

The findings prove that the scale has acceptable reliability and validity, and can help care managers reflect on their practice. Future research is desirable to measure the validation of change in the scale.

Autonomy conquers all: a thematic analysis of nurses’ professional judgement encountering resistance to care from home-dwelling persons with dementia

Background

Adequate care support from home health care nurses is needed to meet the needs of an increasing number of home-dwelling persons with dementia and those who resist care. The decisions nurses make in home health care when encountering resistance from persons with dementia have an extensive impact on the quality of care and access to care. There is little research on what influences nurse’s encounters with resistance to care from home-dwelling persons with dementia.

Research aim

To get insight into how nurses experience resistance to care from home-dwelling persons with dementia.

Methods

A qualitative research design using a thematic analysis was conducted following the six steps by Braun and Clarke. Data was gathered from three focus group and three individual interviews, and a total of 18 nurses from home health care participated. The interviews took place over a period of 5 months, from December 2020 to April 2021.

Ethical considerations

Approved by the Norwegian Centre for Research, reference number 515138 and by the research advisers and home care managers in each section of the municipality.

Results

Two main themes were identified: 1) Challenged by complex and inadequate care structures and 2) Adapting care according to circumstances. There were three subthemes within the first main theme: lack of systematic collaboration and understanding, insufficient flexibility to care, and the challenge of privacy. In the second main theme, there were three subthemes: avoid forced treatment and care to protect autonomy, gray-areas of coercive care and reduced care. The two main themes seemed to be interdependent, as challenges and changes in organizational structures influenced how nurses could conduct their care practices.

Conclusion

Our findings indicate that nurses’ responsibility to decide how to conduct care is downplayed when facing resistance. Further, their professional judgement is influenced by contextual factors and characterized by a strong commitment to avoid forced treatment and care.

A continuous challenge is to safeguard shared decision-making at the same time as it is balanced against risks of severe health damage in home-dwelling persons with dementia. A fundamental question to ask is whether autonomy does conquer all, even when severe health damage is at stake.

Individuals' Awareness of and Willingness to Accept Hospital-at-Home Services and Related Factors: A Cross-Sectional Study

Introduction

Hospital-at-home (HaH) services have become increasingly popular. However, the experience of HaH implementation in Asia is inadequate. Therefore, the purpose of this study was to investigate individuals' willingness to accept HaH services and the potential related factors.

Methods

The researchers visited households to select appropriate participants. An online questionnaire survey was conducted among the inhabitants of selected communities. An individual's awareness, willingness to accept HaH services, and demands such as ideal service providers and more detailed information to accept HaH care were investigated. The outcome measure was the willingness to accept HaH services. Chi-square tests and logistic regression models were used to analyze the factors.

Results

A total of 622 subjects participated in this study. The findings indicate that 55.9% of the participants were not aware of HaH services, while most of the subjects (88.4%) were willing to accept them. Regression models indicated that having health insurance (OR = 2.170, 95% CI: 1.003–4.697), an awareness of the necessity of HaH services (OR = 4.721, 95% CI: 2.471–9.019), very much hoping staff from central hospitals would be service providers (OR = 20.299, 95% CI: 5.718–72.068), and somewhat hoping that staff from central hospitals would be service providers (OR = 9.139, 95% CI: 2.714–30.775) were the factors associated with a greater willingness to accept HaH services.

Conclusion

The study indicates that compared to the awareness of HaH care, residents had a greater willingness to accept such care. The willingness to utilize HaH services among individuals was associated with enabling factors, predisposing factors, and HaH-related demand factors.

Iatrogenesis in the context of residential dementia care: A concept analysis

Background and Objectives

This concept analysis aims to explore iatrogenesis within the context of residential dementia care and to distinguish this phenomenon from similar phenomena, such as abuse and inadvertent harm.

Research Design and Methods

Walker and Avant’s method for concept analysis was used to define critical attributes of iatrogenesis within residential dementia care, and to explore antecedents and consequences of its occurrence. A review of the literature about iatrogenesis in the context of residential dementia was conducted across 4 electronic databases. Texts about iatrogenesis in surgery, medicine, social work, psychology, and other relevant disciplines were also reviewed to provide additional context for the concept.

Results

Iatrogenesis takes a unique form in residential dementia care. The final definition of the concept proposed in this article is habituated, forceful, hands-on care provided to residents who exhibit responsive behaviors that result in emotional, physical, spiritual, social harm, and/or gradual functional decline, that is provided with the intention of supporting the resident’s safety and dignity.

Discussion and Implications

The definition of iatrogenesis proposed in this article is an initial step toward developing evidence-based practice for the provision of nonconsensual assistance in residential dementia care. A theoretical definition like the one proposed in this article may serve as a starting point for the operationalization of the concept, which would promote future empirical research into staff and residents’ experiences of health care-inflicted harms in this context. Theoretically, it contributes to critical conversations about the narratives, myths, and misperceptions that facilitate the provision of nonconsensual care.