AUDIT PROJECT

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Toward Active Old Age conference 24.4.2004
Pori,Finland
Dr. Kari A Sirkka Prof. Merja Nikkonen
The UN Principles of Older Persons in European
Elderly Care Environments
-A Community Analysis on Elderly Care
Environments in Four European Countries
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Toward Active Old Age conference 24.4.2004
Pori,Finland
Research questions

• How do the UN Principles of Older Persons
  (46/91) appear in the elderly care practice from
  perspectives of physical, psychosocial and
  symbolic care environments in the target
  institutions selected in the four European
  countries?
• What are the similarities and diversities
  regarding the basic elements constructing
  physical, psychosocial and symbolic elderly care
  environments in the target institutions selected
  in the four European countries?
• What kind of overview and future challenges does
  the sample provide of the elderly care culture in
  the target institutions selected in the four
  European countries?

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Methodology

• Toward Active Old Age project members chose the
  target institutions in each of the four countries
  involved in this study. The institutions were
  supposed to be the average level elderly care
  institutions in the country in order to provide a
  more general perspective to elderly care
  environments in each country.
• The staff and residents in each target
  institution were informed in advance about the
  contents, the means used and the purpose of this
  study. All the information published in this
  report is based on free personal consents to be
  used as informants (by observation, interviews,
  photographing) in this study. A copy of this
  report will be delivered to each institution
  involved.
• The data collection process was independent from
  the institutions (translator not working for/ in
  the institution) objectivity

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Methodology

• The data collection and analysis followed the
  four-phased Genesis- community analysis model
  (Artinian Conger 1997, 180-182 STAKES 2003)
• organising the audit visits in each target
  institution. The institutions involved sent the
  authors package of information consisting the
  generic information (with some statistics), care
  philosophy and areas of care activities of the
  institution
• 2) two-day audit visits in each institution
  (audit programs included general tours in the
  institutions, meetings with the administration,
  staff, residents, relatives, civil servants
  dealing with elderly care, as well as spontaneous
  talks with people in their daily activities)
  the observational data was collected
  simultaneously during the rounds and interviews.
  Each audit day ended by checking and comparing
  the data both authors had collected. Also the
  management of each institution organised a short
  meeting for briefing the spontaneous impressions
  and notices done during the audit days.
• focused on deeper thematic analysis by means of
  a qualitative constant comparison method that
  involves the systematic sifting and comparison of
  items of interview- and observation memos to
  reveal and establish an internal structure of
  categories (Green 1998)
• drawing the conclusions and publishing the
  findings according to the order of the UN
  principles

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Study design
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Reflections on the findings

• Care philosophy
• Audited organisations represent a variety from
  medicine-oriented institutions to centres of
  diversified residential and non-residential care
  services
• the most common issues named as valuebasis
  despite of the type of organisation were
• home-likeness
• respect of a person
• holistic care
• self-reliance
• rehabilitation

Organisational value basis in care

• The concepts are not so clear among staff
  members, and the terms require organisational
  level definitions and agreements on what they
  mean in OUR SERVICES

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Reflections on the findings

• Staff qualifications and other requirements
• The amount of qualified staff varies between 40
  94
• ? The more qualified staff the more medicalised
  the care
• Despite of the organisations philosophy or
  ideological frame, the staff members are hired to
  do certain tasks or fill certain posts
• tend to maintain power structure on staff- or
  task-orientation in services (rather than client-
  or life phase orientation)
• Investments on the well-being of the staff were
  not done too much (except some annual parties
  no systematic training programs, prizing or other
  motivation systems)

Organisational value basis in care
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Reflections on the findings
INDEPENDENCE
1. physical environment
factors facilitating self-reliance, autonomous
living, and safe activities in physical
environment
 AQUARIUM SYNDROME ?TOO EXTRAVAGANT OR TOO
POOR FACILITIES SEEM TO HAVE SAME AFFECT TO
DEPRESS INDEPENDENCE ?BUILDINGS AS ARCHITECTURAL
MONUMENTS LABEL AND SEPARATE RESIDENTS FROM OUTER
SOCIETY AS MUCH AS POOR FACILITIES SAFETY
RISKS ? RISKS IN PERSONAL SAFETY REQUIRE PERSONAL
ALARM SYSTEMS (not only apartmental ones)
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Reflections on the findings
INDEPENDENCE
2. psychosocial environment
a question of personal freedom,
self-determination in decision-making and dignity

•  KEEPING TOUCH TO SOCIETY
• ALL INCLUSIVE INTRA-MURALSERVICES DIMINISH NEED
  OF GOING OUT OF THE BUILDING
• MIGHT SUPPORT INDEPENDENCE IN THE HOUSE BUT
  REDUCES ABILITY TO MANAGE IN EXTRA-MURAL SOCIETY
• ECONOMIC INDEPENDENCE
• ? POVERTY IS AN EVERY DAY REALITY AMONG THE
  ELDERLY

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Reflections on the findings
INDEPENDENCE
3. symbolic environment
balancing oneself with taking the risk of
being a burden to the staff when asking help or
giving up and loosing the autonomy

•  PERSONAL IDENTITY AND FREEDOM
• INDEPENDENCE IS A QUESTION OF PRESERVING ONES
  PERSONAL FREEDOM, IDENTITY, BEING A SUBJECT OR A
  PERSON
• PERSONAL FACILITATING
• ? SAFETY IS TO RECEIVE TRUSTWORTHY SUPPORT IN
  DECISION-MAKING PROCESSES AND HAVING SOMEONE AS
  RESIDENT'S ADVOCATE (TRUST)

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Reflections on the findings
PARTICIPATION
1. physical environment
physical factors facilitating involvement and
attendance in various activities

•  ENTERTAINMENT SYNDROME
• ACTIVITIES FOCUSED MOSTLY ON ENTERTAINING RATHER
  THAN DEVELOPING THE RESIDENT'S FULL MENTAL AND
  KOGNITIVE POTENTIAL
• ? PARTICIPATION IS NOT QUESTION OF ROOM IN THE
  FIRST PLACE (transport, attitude, encouragement,
  meaningful activities)

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Reflections on the findings
PARTICIPATION
2. psychosocial environment
as issues related to being a subject (or
object) and possibilites to attend to societal
activities as an ordinary citizen
PARTICIPATION REQUIRES MOTIVATION ? CREATING
MEANINGFUL AND BENEFICIAL ACTIVITIES TO
PARTICIPATE IN (passive participation does not
necessarily produce well-being) ? BREAK DOWN OF
MENTAL BARRIERS HINDERING THE INVOLVEMENT IN THE
DAILY LIFE IN THE HOUSE (standing at the door
side of the kindergarten rather than daring to
get involved etc.)
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Reflections on the findings
PARTICIPATION
3. symbolic environment
commitments in allowing personal freedom and
investment both in human resources and the
technical aids

•  UTILISING ELEMENTS OF MEANINGFUL LIFE AND HUMAN
  RESOURCES
• ?PERSONAL SKILLS, KNOWLEDGE AND LIFE EXPERIENCE
  IN BETTER USE
• MINIMUM LEVEL LIFE
• ? ACCEPTING EXTERNAL REGULATION, BEING HAPPY TO
  LIVE EASY LIFE IN ENVIRONMENT WITH BASIC
  SERVICES

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Reflections on the findings
CARE
1. physical environment
hygienic facilities, variety of technical
aids, dining facilities, and human resources
invested on care

•  DO GOOD FACILITIES QUARANTEE GOOD CARE?
• ? CARE STILL OFTEN SEEN AS WORK CONFINED TO
  CERTAIN SPACE RATHER THAN TRANSFERRABLE OR
  MODIFIABLE (professional or non-professional)
  ACTIVITY
• LIVING IN THE HOTEL gtlt HOLISTIC CARE

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Reflections on the findings
CARE
2. psychosocial environment
attempts to deal with physical, mental and
social needs in the frames of societal resources
  WELL-BEING AND LONELINESS ? CULTURALLY
LABELLED CONCEPTS ? PROFESSIONALS TOO HASTILY
DIAGNOSING AND FINDING SCIENTIFIC EXPLANATIONS
INSTEAD OF LISTENING THE MESSAGE  ? WHAT CREATES
THE SENSE OF BEING CARED FOR? 
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Reflections on the findings
CARE
3. symbolic environment
. 1) activities supported or implemented by
persons authorised to the task, 2) standard
package of services based on diagnosis or care
plan, 3) as various packages of services
provided according to mutual agreement with the
customer

•  LIFE-ORIENTATION, PERSON-ORIENTATION OR SERVICE
  ORIENTATION?
• VARIETY OF CARE ACTIVITIES AVAILABLE ("SOMETHING
  FOR EVERY ONE") INSTEAD OF UTILISING NORMAL
  SITUATIONS TO CARE PURPOSES (like reminiscing,
  health education, history projects, exhibitions
  etc)
• TAILORED SERVICES MAY LEAD TO
• -risk of purhasing services more than finance can
  afford
• -unequality among the residents

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Reflections on the findings
SELF-FULFILMENT
1. physical environment
physical factors maintaining ones personal
identity and the image of ones real
possibilities to go on with ones own life

•  PRIVACY
• PERSONAL SPACE WITH POSSIBILITIES TO KEEP
  PERSONAL BELONGINGS VARY FROM 60 CM SHELF (IN 3
  M2 SPACE) TO 55 M2 PRIVATE APARTMENT
• ? HOW TO INTEGRATE PRIVACY AND COMMUNALITY

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Reflections on the findings
SELF-FULFILMENT
2. psychosocial environment
possibilities to utilise the knowledge and
skills of the elderly. Being active understood
as physical activity

• INVESTMENT ON HUMAN DEVELOPMENT
• VERY LITTLE INVESTED ON EDUCATION OR HUMAN
  DEVELOPMENT
• THE RESIDENTS PROFESSIONAL KNOWLEDGE, SKILLS OR
  LIFE EXPERIENCES NOT UTILISED IN FULL POTENTIAL
  (i.e. in collaboration with schools, day care
  units, adult education centres)
• ? VISION OF DOING THINGS THAT WERE NOT POSSIBLE
  BEFORE RETIREMENT SEEM TO BE GIVEN UP

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Reflections on the findings
SELF-FULFILMENT
3. symbolic environment
beliefs in being aged differ between helpless
children, exploited financial resource for the
rest of the family to respected persons as long
as one is able to take care of ones own business

• DREAMING ABOUT SAFE AND WORRILESS LIFE
• ? AGEING IS NEVER A PROBLEM AS LONG AS ONE IS
  ABLE TO CARE FOR ONESELF
• TASK ORIENTED ELDERLY CARE IS NOT APPEALING BUT
  HOW ABOUT PERSON- OR WELL-BEING ORIENTED CARE?
• ? SIFFICULTY TO KNOW WHAT YOU ARE ALLOWED TO WANT
  AFTER LONG HISTORY OF HAVING NO OPTIONS

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Reflections on the findings
DIGNITY
1. physical environment
principles of both physical and mental safety
and respect of ones privacy
 PHYSICAL gt lt MENTAL SAFETY ? WHERE DOES THE
DANGER STAND (INSIDE OR OUTSIDE) ?
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Reflections on the findings
DIGNITY
2. psychosocial environment
respecting one as a person, kind behaviour,
equality in approaching the residents, and
making various activities as nice and comfortable
as possible to the residents

• SOCIAL gt lt ETHICAL SAFETY
• ? BOARDING HOUSES (with all inclusive full board)
  MAY TURN TO BEING BORED -HOUSES
• GOOSE MARCH PHENOMENON
• ? SERVICES OFFERED SHOULD NOT TURN TO FINANCIAL
  EXPLOITATION

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Reflections on the findings
DIGNITY
3. symbolic environment
opportunities to maintain ones personal life
style and taste
PERSONAL SAFETY ?FREEDOM TO BE WHO YOU
ARE Nothing would change even if the Queen
moved in here ? EQUALITY BETWEEN RESIDENTS AND
THE STAFF
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Typology of elderly care institutions
SOCIAL SHELTER RESIDENTIAL RESORT CLIENT-CENTRED COMMUNITY INTERSUBJECTIVE WORLD
-place to stay safe in risky situations -societal obligations -sometimes isolated from other society -boarding house with restricted entrance -often requires adaptation to standard service packages and inmate culture -depending on ones own health condition activity of the relatives -economic situation -membership on voluntary basis -freedom based on the organisations commitment to certain ideology -personal state of freedom -freedom to go on with ones own life -self-determination -interpreting and understanding human life as ones lived experiences -meaningful life
-work orientation stressed on professionalism and based on the professionals views on the contents of care -work orientation stressed on professionalism and based on the professionals views on the contents of care -work orientation based on roles in the community -clients voluntarily chosen the institution as their place of living -work orientation strive for meaningful life for the residents and clients
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Future challenges

• Institutional level
• -flexibility and integration of fragmented
  services for everybodys benefit
• -development of new approach to services
• (life histories education for third age
  resource-thinking etc.)
• -facilitating and empowering staff and residents
  together to innovations
• (creating possibilities for residents to develop
  their self- fulfilment in full potential)
• -changing philosophy from medicalisation or
  uniformed charity to serving clients based on
  their individual needs
• (well-being rather than treatment)
• -actions to encourage family involvement in
  clients lives

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Future challenges

• Residential/ client level
• -claim of bigger role and involvement in ones
  own care life in institutions
• -shortage of meaningful activities
• -utilisation of residents knowledge and skills
  better in voluntary work (meaningful things to
  do)
• -lack of privacy
• -how to maintain the same level in dignity when a
  person got ill or demented?
• -connections with family members
• (phone connections, facilities to spend time
  together)
• -financial situation due to poor social security
  should not affect the residents status as
  citizens and human beings

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Future challenges

• Staff level
• -getting rid of traditional burden of doing on
  ones behalf to keep wheels running
• -avoiding the culture of separation among/
  between the staff and the residents
• -changes in working culture from task
  task-centred thinking to client- or
  service-oriented approach
• -focus more on well-being
• -from job/ position -orientation to facilitating
• -focus set on the sense of becoming cared
• -obtain and apply new knowledge on elderly care
  (gerontological, resource oriented approach to
  care)
• -clarifiying organisational/ personal values on
  regular basis (esp. how to apply into practice)

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THANK YOU FOR YOUR ATTENTION
www.activeoldage.com Satakunnan
ammattikorkeakoulun raportit 1/2004