Residential aged care

Accompanying the demographic shift towards older populations, there is a projected increase in the prevalence of dementia and multimorbidity.6 7 This means that not only are people living longer, but they are also living with more complex physical and cognitive needs, as well as a greater dependency on others to provide assistance with basic needs (eg, showering, mobility or eating). Dependent older individuals may require full-time care that their family members are not always able to provide.8 This places particularly high demands on residential care services in terms of funding, physical resources (eg, beds and equipment) and human resources, including workforce and training.

Unlike other healthcare systems, such as acute or primary care, residential aged care facilities (RACFs) serve as a home for consumers,9 10 providing social care, spiritual care, meaningful activities and physical assistance, in addition to medical care.11 RACFs must deliver round the clock care in which care staff are available to meet residents’ varied needs, as well as managing interruptions to routine care, such as unexpected illness or injury.

Prioritising care

Despite being high-dependency environments, RACFs often lack adequate human resources in terms of both staffing levels and skill mix.12 13 These shortages and consequent time constraints mean that staff must continually prioritise and re-prioritise the care they provide by adapting to the situation at hand. Prioritisation can be understood as ‘putting first’, implying that something that is important or urgent has priority over what is less important or less urgent’.14 Priority-setting, or prioritisation of care, requires care staff to rank care activities in a hierarchical fashion according to the level of importance, where some tasks are assigned a lower priority. The action by which a lower priority care task is decisively traded off in favour of a higher priority task is known as ‘implicit rationing’.15

Prioritisation of tasks can result in ‘missed care’,13 which is ‘any aspect of required patient care that is omitted (either in part or in whole) or delayed’.16 Essentially, it is care that has fallen through the cracks in a complex—often, pressurised—system. Across acute and residential care settings, missed care is associated with poorer consumer outcomes, such as urinary tract infections, patient falls, pressure ulcers, and reduced patient satisfaction and quality of care.17

The priorities of key stakeholders in RACFs

Research on prioritisation and missed care predominantly focuses on the priorities of healthcare professionals, particularly nursing staff.17–19 This narrow focus limits our understanding of prioritisation by emphasising a single viewpoint instead of acknowledging healthcare systems as complex networks made up of diverse stakeholders. In RACFs, these networks comprise residents, family members, direct care staff (eg, carers, registered nurses and management), domestic staff (eg, cleaners), allied health professionals (eg, speech pathologists and physiotherapists), visiting healthcare professionals (eg, physicians and dentists), volunteers, advocate groups and policy-makers.

Each stakeholder holds a distinct role, accompanied by different responsibilities and challenges, which can influence their priorities, that is, what is most important to them when it comes to care. For this proposed study, we focus on three central stakeholder groups: residents, family members and care staff. Figure 1 presents a selected summary of role challenges these stakeholders face, based on the literature.12 20–24

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Figure 1

A selection of stakeholders’ role challenges.

Rationale

The research team systematically reviewed the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework25 to ascertain the current state of knowledge on ‘unfinished care’—a collective term encompassing prioritisation, rationing, missed care, omitted care and care left undone.18 The majority of included studies examined the scope of the problem (eg, what care is missed, delayed or left undone) and antecedents (eg, what factors contribute to unfinished care, such as inadequate staffing or time constraints).13 26–28 Few studies directly assessed prioritisation,29–31 demonstrating that there is limited knowledge about how care is prioritised in RACFs, particularly within the recent literature.

To deliver care that is more consumer-centred and takes the needs, as well as role challenges, of different stakeholders into consideration, it is important to obtain a deeper understanding of each groups’ care priorities; what they value as most important in terms of care delivery. To the best of our knowledge, no other study has made comparisons between how care is prioritised by key stakeholder groups in residential aged care. The following objective and research questions were developed to address this gap.

Theoretical considerations

The ways in which stakeholders prioritise care will be investigated through Q methodology. Q is a research method used to systematically study subjectivity and identify divergent viewpoints (factors), through the integration of quantitative and qualitative techniques.32 33 While the Q approach is a method of doing research, in our work, we also draw on its theoretical underpinnings. In doing so, we make a number of assumptions. First, we assume that individuals are able to express their subjective views on what they value most (their priorities). Second, this subjectivity can be systematically collected and studied through Q methodology.33 34 Third, the number of distinctive viewpoints on a topic of interest is limited, known in the terminology of Q as ‘finite diversity’.35 Here, we assume that based on our use of Q, individuals’ priorities can be examined to identify distinct, cohesive viewpoints shared by a number of participants.

In exploring the priorities of different stakeholders and making comparisons between them, we are also adopting a complexity lens.36 Through this lens, we view RACFs as complex systems, comprising diverse agents who interact and sense-make (interpret the world) in ways that create shared meanings.37–39 For this study, the portions of shared meaning under investigation are stakeholders’ priorities. In a complex system, these collective interpretations are considered the basis for agents’ interactions, which may, in turn, produce broader system-level behaviours,37 40 for example, staff members may adapt to environmental constraints such as inadequate time or staff shortages by delaying or omitting aspects of care that are given lower priority.

While these broad theoretical and methodological principles guided our choice of method, we have avoided, at this stage, selecting a mid-range theory related to prioritisation, decision-making or care delivery in aged care. Q methodology is particularly suited to exploratory research, and it is then a convention to return to established theory to interpret results35; this will be the case for the proposed study, to understand the types of priorities participants have.

Inclusion criteria

In order to participate in the study, participants must meet the following inclusion criteria: (1) be a current resident, family member of a resident or a staff member at a RACF; (2) have willingness and ability to provide informed consent; and (3) have the capacity to participate in an English-language interview. Additionally, resident participants can only be included in the study if their participation will not cause them any additional physical burden. Residents with mild cognitive impairment may participate in the study if they are able to give informed consent, as advised by facility management.

Consent

Consent will be obtained from all participants in written form or verbally if participants are unable to provide written consent. Due to the potential inclusion of residents with mild cognitive impairment, the proposed study will employ an ongoing consent process (process consent), in which consent is verbally re-confirmed throughout the study.53 Participants will be informed both verbally and within the PICFs that there is no obligation to participate in the study and that they can withdraw from the study at any time without consequence. If participants decide to withdraw during the study, they will be asked to sign a Withdrawal of Participation Form and no further personal information will be collected.

Demographics questionnaire

The demographics questionnaire has been designed to cover the following topics: age; gender; how long the participant has lived, worked or has had a family member living at the participating RACF; a self-reported single-item measure of health (residents); job title (care staff).

Q sort deck

The Q sorting activity will require participants to order aspects of care by level of importance using a set of cards (Q sort deck), each displaying three elements: a statement about an aspect of care; a visual representation of the corresponding statement and examples of the care element (figure 2). The Q sort deck was developed through a five-stage process:

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Figure 2

Example card: management of medical condition(s).

Stage 1: a comprehensive list of elements of care in RACFs, known as ‘the concourse’ was devised through a review of the literature.33

Stage 2: concept mind mapping54 was used to reduce the concourse to a subsample of items known as the Q set.55 A smaller Q set (n=34) will be used in this study in order to reduce the cognitive demand placed on resident participants, while adequately covering the range of care provided in RACFs.

Stage 3: Q set items were modified into statements suitable for ranking by each participant group, for example, My medical conditions are managed (resident statement); My family member’s medical conditions are managed (family statement); and Residents’ medical conditions are managed (care staff statement).

Stage 4: the Q set was validated by three members of the managerial team from one of the participating sites to ensure that key aspects of care had been covered and that the language was appropriate and relevant for participants.

Stage 5: the Q set was transformed into a physical Q sort deck comprising a set of magnetic cards.

Q sort diagram

Cards will be sorted using a pre-established grid (Q sort diagram), which comprises a quasi-normal forced distribution with a rating scale from −4 (Least Important) to +4 (Most Important) (see figure 3). The Q sorting activity will be conducted on a whiteboard with the Q sort diagram transposed on, allowing for easy attachment of magnetised cards.

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Figure 3

Q sort diagram. 

Semi-structured interview questions

Semi-structured interviews will be tailored to each participant group and will address the following questions:

• What influences participants’ priorities?

• How are participants’ priorities communicated?

• How do priorities compare between different participant groups (eg, how do residents’ priorities compare with the priorities of care staff)?

• What happens when priorities are not met?

• How do care staff manage their priorities when delivering care?

• What challenges prevent care staff from meeting their priorities when delivering care?

• Is there any further information about priorities that participants want to discuss?

Q sorting activity and think-aloud task

Participants will be guided through the Q sorting activity using established Q methodology techniques.56 This will involve sorting the Q sort deck onto the Q sort diagram using the following condition of instruction: order the cards from ‘least important’ to ‘most important’ in terms of the care provided to you (residents); your family member (family members); or residents (care staff).

Concurrent to the Q sorting activity, participants will be asked to engage in a think-aloud task,41 42 where they will be prompted by a member of the researcher team to vocalise their thoughts as they sort the cards.56 The think-aloud task was piloted with an initial group of participants who found value in the opportunity to vocalise and explain their decisions. This task is a personalised one in which participants can engage to the degree to which they are willing and able. On completion of the Q sorting activity, participants will be asked a series of open-ended questions about the way they sorted the cards (Q sorting). Post-Q sorting interviews will assist in the interpretation of individual Q sorts as well as the interpretation of shared viewpoints across participants.51 Questions will focus on the placement of salient cards and the decision-making process, and will build on responses from the think-aloud task.

Demographics questionnaire and semi-structured interview questions

Following the Q sorting activity, participants will be administered the demographics questionnaire. They will be given the option to complete the semi-structured interviews immediately after the demographics questionnaire or at another time if they prefer. The Q sorting activity, think-aloud task, demographics questionnaire and semi-structured interviews will be audio-recorded with participants’ consent. A member of the research team will take field notes during interviews noting the context, participant mood, non-verbal behaviours, pace of decision-making and any interruptions to data collection. The audio recordings and field notes will ensure that participants’ responses are accurately captured.

Alternative administration

Participants unable to attend on-site data collection will be offered an alternative method of study administration in which the demographics questionnaire and Q sorting activity are administered via VQMethod, an online tool that mirrors physical card sorting.57 The semi-structured interview section of the study will be offered via telephone.