My home life, or our home life The risky road to quality Presentation by Mike Nolan Professor of Ger

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My home life, or our home life?The risky road
to qualityPresentation byMike NolanProfessor
of Gerontological NursingUniversity of
Sheffieldto The National Care Forum 2006
Managers Conference6 November 2006
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You cant discuss something with someone whose
arguments are too narrow
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Risk Towards a broader view

• Risco Italian for danger
• Expose to risk (ie danger, loss, injury)
• Accept the chance of risk
• Venture on
• (Oxford English Dictionary)
• Risk is becoming taboo
• To avoid risk is to avoid challenge
• Must challenge dominant view of care homes and
  those who live and work in them

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Care homes a legacy of stigma

• the large scale review amounts to a rebuke
  for the care home system
• ..residential care homes have never enjoyed high
  public esteem, or even much public or political
  interest (Dudman 2006)
• Requires a vast cultural change (Dudman 2006)

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How did we get here?

• deep rooted cultural attitudes
• Stepping back in time
• Fee for service if you could afford it
• Voluntary hospitals centres for scientific
  medicine, training of doctors, and the treatment
  of the acutely ill
• Workhouses incurables old and chronically
  ill
• Emergence of the professional elite hospital
  based consultants reinforced emphasis on cure
  at the expense of prevention
• NHS Beveridge Report warned against being
  lavish to old age

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Emergence of geriatric medicine

• Single most important contribution of the NHS to
  the care of older people
• (Wilkin and Hughes 1986)
• Heavily resisted by acute medicine and surgery
  no value in spending time, money, energy and
  bed space on redundant senior members of
  society
• (Felstein 1969)
• Pejorative discourse of incurables replaced
  with that of bed blockers
• Geriatric medicine offered a potential way out

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Therapy as technical, diagnostic, treatment
role Therapy as nurture and support

• The treatment - technician model is seen as more
  prestigious, more skilful and more desirable

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If not cure then rehabilitation

• This they have achieved by substituting
  rehabilitation for cure. Medical interventions
  in geriatric medicine operate on a continuum
  between dependence and independence rather than
  health and illness. The medical model has been
  shifted in the direction of a functional
  conception of health. In this way it is possible
  to achieve success measured in terms of patient
  throughput
• (Wilkin and Hughes 1986)

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The geriatric model

• Rehabilitation function and independence
  emphasises the capacity of old people to lead
  independent lives so that continued dependency
  comes to be regarded as failure
• (Wilkin and Hughes 1986)
• Progressive patient care
• Acute ? rehabilitation ? continuing care
• Reinvents the incurables who are subject to
  aimless residual care
• (Evers 1991)
• What of care homes?

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Sign of final failure

• (Victor 1992)
• Community care occupies a morally and socially
  unassailable position
• (Stone 2001)
• Whereas the care home evokes images of
  abandonment and family failure, home care
  promises independence and social integration
• (Stone 2001)
• Participants from both age groups also had very
  negative ideas about nursing homes
• (Stratten and Tadd 2005)

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Where are we now?

• Independence, well-being and choice our
  vision for the future of social care for older
  adults in England
• Billions in taxpayers cash should be pumped into
  helping people stay in their own homes rather
  than moving into residential care

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Lets get critical!

• Complex concepts such as dignity (independence,
  care) are frequently cited but rarely defined,
  and often taken for granted. Whilst their
  importance is intuitively recognised their
  complexity is not and they are often reduced to
  simple things such as privacy and the exercise of
  choice.
• (Edgar and Nordenfelt 2005)

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What do we value?

• The fantasy of modern life is celebrated in
  advertising and the media as the healthy, fit
  young adult, or the well preserved, vital senior
  citizen each shaping a fast paced life of
  unlimited horizons and unimpeded self-direction
• (Callahan 2001)
• In the West we inhabit a youth dominated
  culture, to be old in the 1990s might therefore
  be a worrying prospect. To be old, dependent and
  ill could be a terrifying one
• (Garner and Ardern 1998)

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Successful ageing whats not to like?

• (Scheidt et al 1999)
• How is success defined?
• Three prerequisites for successful ageing
• - Avoidance of disease and disability
• - High levels of physical and cognitive
  functioning
• - Active engagement with life
• (Holstein and Minkler 2003)
• Use of term successful itself is problematic as,
  by definition, it casts those who do not meet
  the canons into the alternative unsuccessful
  category
• Constitutes the new ageism (Holstein and
  Minkler 2003) based on a vision of the
  super-aged (Feldman 1999)

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So whats the problem?

• A society that valorises youth and informs
  people that successful ageing is defined almost
  exclusively in terms of health status, is
  potentially damaging personally and
  professionally, it burdens rather than liberates
  older people, and offers an impoverished view of
  what a good old age can be
• (Holstein and Minkler 2003)
• What of care?

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Caring has been devalued

• (Cluff and Binstock 2001)
• The drive for medical cure, the hype of research
  agendas, the classy adds of elders on their way
  to the Galapagos Islands, have managed to make
  caring seem like a second rate activity,
  something we do for the biological losers
• (Callahan 2001)
• Where does this leave care homes?

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Towards a more balanced debate

• Critique of care homes is unidimensional and
  unidirectional fails to address the quality of
  life of similarly frail people living at home
• (Baldwin et al 1993)
• Highly impaired older people at home spend 81 of
  working day passive, only 7 spent on
  potentially enriching activities
• (Lawton et al 1995)

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Person-centred care mantra of the moment

• Care that is based around an individual and their
  needs
• (DoH 2001)
• Key values underpinning the single assessment
  process are person-centred care and independence
• (Norman 2005)
• Assessment is a person-centred activity with an
  emphasis on establishing areas of need to
  maintain or increase independence and quality of
  life
• (McCormack and Ford 2000)
• Havent we been here before?

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Towards a new vision

• Beware the new gerontology with its focus on
  individually successful ageing that results in
  an impoverished view of what a good old age can
  be
• (Holstein and Minkler 2003)
• Autonomy and individuality are incapable of
  underpinning any shared societal responsibility
  for the health of all its members, including the
  least advantaged
• (Evans 1999)
• Need a relational view of autonomy that
  recognises that people are never fully
  independent
• (MacDonald 2002)

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Towards relationship-centred care

• Tresolini and the Pew-Fetzer Task Force 1994
• Major review of the bases for health care
  systems and the way that practitioners operate
  and are trained
• Relationship-centred care
• The phrase relationship-centred care captures
  the importance of the interactions among people
  as the foundation of any therapeutic or teaching
  activity. Further relationships are critical to
  the care provided by nearly all practitioners and
  a sense of satisfaction and positive outcomes for
  patients and practitioners. Although
  relationships are a prerequisite to effective
  care and teaching, there has been little formal
  acknowledgement of their importance, and few
  formal efforts to help students and practitioners
  learn to develop effective relationships in
  health care
• (Tresolini and the Pew-Fetzer Task Force 1994)

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Making relationship-centred care work

• Need to explicate the dimensions of
  relationship-centred care
• (Tresolini and the Pew-Fetzer Task Force 1994)
• To identify the supportive social conditions
  that promote a relational view of autonomy
• (MacDonald 2002)
• To consider the milieu of care needed to
  achieve shared goals
• (Pryor 2000)

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Making sense of enriched environments of care

• The Senses Framework
• (Nolan 1997, Davies 1999, Nolan et al 2001, 2003,
  Brown 2006)
• Security - to feel safe physically,
  psychologically, existentially
• Belonging - to feel part of a valued group, to
  maintain or form important relationships
• Continuity - to be able to make links between the
  past, present and future
• Purpose - to enjoy meaningful activity, to have
  valued goals
• Achievement - to reach valued goals to
  satisfaction of self and/or others
• Significance - to feel that you matter and are
  accorded value and status

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Traditional treatment models lead to
fractionalisation of the patient

• As synthesisers of care we are in the business
  of
• creating the right environment for others to
  grow

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Creating the right environment for others to
grow?

• Not just others but everyone
• If employees are abandoned and abused, probably
  clients will be too. If employees are supported
  and encouraged they will take their sense of
  well-being into their day-to-day work.
• (Kitwood 1997)

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Filling in the gaps
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CARE Profiles

• Combined Assessment of Residential Environments
• (Faulkner et al 2007)
• Based on positive events in the home from the
  perspectives of residents, relatives and staff
• Three separate profiles, one for each group
• Qualitative comments
• What works well, for whom
• What could be improved

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Frequencies of positive events experienced by
residents

• Always
• Never

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My home life

• While the home must be built around the needs of
  residents, active participation and a sense of
  belonging on the part of staff and relatives are
  critical.
• Getting residents, staff members and
  relatives views and making them part of any
  changes which are made should be a priority and a
  requirement for regulation.
• residents, relatives and staff should be able
  to share their experience of quality of life in
  care homes when living and working together.

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