Ensuring effective involvement in decisions about quality in institutional care settings
Article Type: Editorial From: Quality in Ageing and Older Adults, Volume 16, Issue 2.
The vital role of communication and information-giving for older people, providers, policy-makers and regulators of acute and longer-term care becomes more challenging as the care needs of older people become more complex. Some of the challenges are well illustrated by the papers in this issue, which address aspects of assessment, admissions and delivery from different perspectives along the care trajectory, located closer as well as further from direct experiences of care.
The opinion piece by Virginia Minogue offers a very personal account which highlights the vital need to attend to the quality of communication if compassionate care is to be realised in the interactions and relationships which underpin acute care settings. Central to here was the patient’s expressed need to experience active involvement in the important decisions so that such decisions could start from their needs rather than conveying the sense that their needs and dignity might have been considered after decisions were taken, if at all. Finding ways to facilitate the wider involvement of family and relatives in facilitating such communication can help strengthen the sustained engagement of patients with care providers.
However, Schipper’s survey comparing insights from older people in the Netherlands, from those not yet personally facing such decisions with those who have had some experience of living in long-term care, highlights the difficulties posed for older people to anticipate the real extent of their care needs in practice. Those without direct previous involvement in care access decisions and still living in the community may not be sufficiently well-informed to make the right judgement calls. How to provide timely and acceptable information and support to do so may demand new skills and trust-building partnerships for fostering such discussions sensitively.
This is echoed in the qualitative study by Stevens, Raphael and Green examining the experiences of older peoples’ with minimal care needs of admission to nursing homes, which acknowledges the stressfulness of feelings of abandonment and helplessness too often experienced. This underlines the lack of information and choices that may lead to decisions with irreversible consequences for the older person as bridges are crossed and turning points passed. They argue for equal access to appropriate professional assessment and information to support an appropriate decision, including where people are funding their own care as well as in publicly funded care.
Once living in longer-term care, the organisation of personal care tasks may be seen managed primarily in terms of their physical and temporal logistics. Qualitative findings on bathing in residential care, presented here by Holroyd and Holroyd demonstrate how the resident’s experiences extend well beyond the efficient performance of physical tasks if we are to ensure person-centred care where the resident’s experiences and preferences can shape the process. Again responsive and open communication, where the pressures of time can be actively managed and mediated by interpersonal skills are shown to be key to quality here.
Models for regulation in improving quality in residential care are examined by O’Dwyer whose work seeks to find out whether top down or bottom up approaches may be more effective here. Her study drawing on data from 23 European countries compares models in use, showing the wide range of policy-making choices from prescribing standards backed by criminal sanctions to self-regulation perhaps overseen by professional overviewing and accreditation. Her findings call into question the popular assumption that a highly externally imposed regulatory framework on privatised services is necessarily most effective in ensuring standards. Rather she underlines the importance of self-regulation underpinned by a culture of quality improvement combined with adequate long-term investment whether public or private.
The findings presented in this issue underline what may be involved in making decisions which can ensure quality in such care settings. Clearly important is building a culture which encourages effective and interactive communication between older people,their families and care providers at every level.
Fiona Poland
