The influence of protection, palliation and costs on mobility optimization of residents in nursing homes: A thematic analysis of discourse

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Abstract

Background

With the aging of the population, increasing numbers of older people live in nursing homes. Discourse such as policies and standards highlight the need to optimize the mobility independence of residents. This is expected to occur in a way that is safe for residents and staff whilst meeting the residents’ needs. The influence of discourse on health care delivery can be poorly understood, being at times hidden or taken for granted. The aim of this study was to uncover discourse relevant to resident mobility optimization to enable the origins and reasoning behind existing and intersecting policy and practice to be critically appraised.

Design

Narrative literature review and thematic analysis with a focus on discourse were employed for this study.

Data sources

Databases (CINAHL and Ovid Medline) and websites of relevant professional and governmental bodies were accessed.

Method

A literature search centered on retrieval of texts focused on discourses that influenced goals to optimize resident mobility. Database searches for texts covered the period from 1994 to 2011. Iterative thematic analysis focussed on the texts’ socio-cultural context and influence.

Findings

Four discourses emerged that potentially influence goals to optimize resident mobility: safe manual handling; falls prevention; palliative care; and costs and funding constraints to individualized care. These discourses may influence mobility care in the direction of more routinized, passive and dependency support approaches. A common overarching theme was that of collaboration and communication.

Conclusion

Discourses such as safe manual handling, falls prevention, palliative care and cost constraints to individualized care can negatively impact on the goal to optimize the mobility of residents in nursing homes. Inter-professional approaches where staff work collaboratively and communicate well may counter such influences and ensure individualized care that focuses more effectively on resident mobility.

Introduction

With the aging of the global population and increasing numbers of older people living in nursing homes,1 quality of care is a concern. In Australia standards set for nursing homes require that residents’ mobility be optimized through rehabilitation or maintenance therapy (Commonwealth of Australia, 2008a). There is evidence demonstrating the benefits of rehabilitation, functional training and physical activity on the mobility of older people in nursing homes (Forster et al., 2009, Rydwick et al., 2004, Weening-Dijksterhuis et al., 2011). As residents are often dependent on staff assistance to perform functional tasks, staff efforts should be made to restore resident mobility where possible or to otherwise maintain or slow rates of deterioration of mobility.

Current rhetoric (persuasive language or discourse) expects that nursing home environments be safe and comfortable, meet regulatory requirements and be consistent with resident care needs (Care Quality Commission, 2011, Commonwealth of Australia, 2008a). This requires that approaches to resident care accommodate residents’ mobility needs and outcomes. However, goal based tensions (e.g. safety versus resident mobility optimization) can exist when residents require staff assistance to move. The issue is one of risk management, where the risk of resident or staff injury is considered against the risks associated with constrained approaches to resident mobility optimization. Few studies have investigated the impact of care approaches on resident mobility outcomes. A systematic review (Taylor et al., 2011) found only one study that had investigated the impact of safe manual handling approaches on resident mobility and transfer outcomes (Nelson et al., 2008). Given the relative paucity of evidence from randomized trials in this area, it is highly likely that expert opinion has strongly influenced the development of policy and evolution of practice in this field. Such expert opinion falls within the domain of health care discourse.

Ingalill Hallberg (2009), President of the European Academy of Nursing Science, suggests that research should be located within health care discourse. However the existence and power of discourse may not be well understood. Discourses may appear as what is taken for granted, felt to be right or possibly as the persuasion or authority of others such as peers, supervisors, managers, experts or professional bodies. The aim of this study therefore was to uncover and establish the influence of discourses connected to optimizing resident mobility so that the origins and reasoning behind existing and intersecting policy and practice can be critically appraised.

Section snippets

Discourse defined

The term discourse can refer to “language-in-use” (talk and text) as well as a broader use of the word where combinations of thoughts, words, objects, events, actions and interactions create meaning; in other words, the socio-cultural context of the “language-in-use” (Smith, 2007). Discourse is a dynamic process; dialog and interaction result in constant transformation of meaning (Gee, 2005, Hansen, 2006) therefore texts that referred to relevant actions, events and interactions were considered

Search strategy

In the course of working as a physiotherapist in nursing homes for over 20 years, discourses that impact on resident mobility were evident to the first author (JT). Discourses also emerged from many informal discussions with colleagues. The search strategy for literature on discourses was, therefore, purposive and included searching for relevant discourse analyses as well as recent guidelines or literature reviews on each discourse. A snowballing search strategy was used to find literature

Discussion

A welcome emphasis on safety regarding resident manual handling has emerged in nursing homes as a result of socio-cultural forces, in particular nursing leadership and advocacy. Palliative care and falls prevention, but also restraint prevention, have emerged as important discourses relevant to nursing homes. Whilst these are positive movements, the same socio-cultural forces are ambiguous regarding how safety and quality care concerns and the imperative to optimize resident mobility will be

Conclusion

It is important to examine the intersection of various discourses that relate to resident mobility. The danger for the mobility of residents in nursing homes to be ignored or be seen as an issue of little significance is inherent within each of the discourses presented in this paper. In the current environment, which is sensitive to costs of care, it could be pragmatic to overlook dependency support behavior in nursing homes. Such practice would most likely be unintended, ignored or covert.

Acknowledgements

Assoc. Prof. Haines is supported by a National Health & Medical Research Council Career Development Award.

Janice Taylor is supported by Primary Health Care Research Evaluation & Development Fellowship 2009.

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