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Nursing home quality
Rights, risks, and autonomy: a new interpretation of falls in nursing homes
  1. A Ryan
  1. School of Nursing, University of Ulster, Coleraine, Northern Ireland, UK; aa.ryan{at}

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    Achieving the balance between safety and the right of nursing home residents to dignity, choice and self-determination is a challenging issue.

    Families caring for older people worry particularly about the safety of their vulnerable relatives. It is often such concern about safety that prompts the final decision to seek nursing home care. In many cases this follows a lengthy period of care in the community where the physical safety of older people may be compromised to respect their right to self-determination and choice. For many families, underpinning the decision to opt for institutional care is the belief that at least their relative will now be safe.

    With demographic trends predicting an increase in the number of older people and a reduction in the number of carers,1 it is likely that admission to nursing homes will continue to increase. In light of this, initiatives such as the National Service Framework for Older People2 and the “Essence of Care” benchmarking project3 are setting new standards of care for older people. In his paper in this issue of QSHC, Kapp4 highlights many issues that people with an interest in the health and social care of older people will readily appreciate. Few will disagree that the issue of safety is as complex as it is poorly defined. While there can only be a consensus that care homes should provide safety and security, the issue of what exactly constitutes a safe environment warrants further exploration. Clearly, there are many instances where the safety of nursing home residents is compromised through adverse drug reactions, injurious falls, and pressure ulcers. However, it would be remiss to suggest that these problems are unique to the nursing home sector when, in fact, they clearly occur in other settings also.

    Protecting the right of vulnerable older people is an issue of international importance. In the UK, care homes are closely monitored by a system of scrutiny that includes a number of visits by the Registration and Inspection Unit. Interestingly, the care of older people in acute settings is not subject to this degree of independent scrutiny. One cannot but speculate on the findings that might emerge if this were, in fact, the case. Put simply, any initiative aimed at enhancing the quality of care for older people must transcend specific locations and reflect an underlying philosophy that recognises the need to balance rights with risks.

    One effect of an increasingly litigious society is to encourage staff to restrict the activities of the older people in their care.4 However, this surely begs the question as to the cost to the overall well being of the older person at which this is to be achieved. Safety will always be a key issue in nursing home care, but questions need to be asked about exactly who is being safeguarded. Is it the resident? If so, is it his/her right to dignity, choice and self-determination even in the face of real or perceived physical risk? Is it the nursing home owners whose determination to avoid negative publicity and litigation overrides any concern for resident autonomy? Perhaps the problem rests with families who may be uncomfortable about the physical safety of their relative being jeopardised. This is especially pertinent in situations where concerns about falls may have triggered the nursing home admission. In such instances, relatives are perhaps justified in expecting to see a decrease in the frequency of such falls following nursing home placement. If this does not occur, relatives may understandably question the merits of their decision. However, at a more realistic level, it is likely that the genesis of the problem rests with all key parties (residents, relatives and staff) and, this being the case, so too does the solution.

    There is a general consensus that a good nursing home is one that provides a homely environment. Should residents with mobility problems therefore have the right to walk freely and unsupervised (as they would at home), even if this brings with it an increased risk of falling? From a nursing perspective, this is a difficult and challenging issue. The negative consequences of immobility have been well documented. However, initiatives aimed at promoting mobility carry a risk of falls. Falls in turn lead to immobility and ultimately the negative consequences that one initially sought to avoid. Of course, no family member wants to hear of a relative falling, and openly addressing safety problems may subject a nursing home to negative publicity. However, more effort should be made to contextualise safety with due regard to the maintenance of a home-like environment and the residents’ right to dignity, participation, and self-determination.

    It would be naïve to underestimate the real risks in adopting such a position, and cynics are justified in believing that some institutions may abuse this liberal approach. However, if we are serious in our effort to address residents’ autonomy, a tripartite approach involving residents, relatives, and nursing home staff will have to be the norm. This is wholly consistent with the concept of “relationship-centred” care5,6 which proposes that the enhancement of relationships should be at the centre of education and practice. Nursing home staff who show a genuine willingness to respect residents’ autonomy cannot continually live in fear of litigation. Similarly, residents and relatives must appreciate the fine balance between rights and risks that will continuously have to be negotiated in a client-centred environment.

    Fostering the innovation and creativity that is required to address the issue of resident safety in such a broad context is a huge challenge. In an ever increasing client-centred environment, it will continue to gain momentum and, as the older people of the future, we would be well advised to take note!

    Achieving the balance between safety and the right of nursing home residents to dignity, choice and self-determination is a challenging issue.


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