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Safe and sound: Autonomy or authority in care homes?

Jennefer Richmond

I was recently asked to review an older patient who was temporarily residing in a nursing home. The patient in question (Cyril) was a gentleman in his 80s – a person with bilateral amputation whose diabetes was controlled with insulin. Cyril was fiercely independent and the only reason he was in the nursing home was that his wife, his main carer, had been admitted to hospital.

When I visited Cyril the staff told me they were concerned that, due to his failing eyesight, he was not giving himself the correct doses of insulin. They had observed him on a number of occasions dialling up incorrect doses on his insulin pen. When the staff challenged him about this, he had resorted to injecting his insulin before anyone had a chance to go into his room. During our conversation, it became clear that he was a highly intelligent individual and any hint that he was not able to self-manage his diabetes was met with fierce resistance.

In fact, when I attempted to check that he was using his pen correctly and dialling the correct doses of insulin he became irate and accused us, the nursing staff, of ‘trying to trick him’. The situation was diffused by telling Cyril that his safety was our main aim and by showing him newer pens with clearer markings to which a magnifier could be attached. Cyril calmed down and accepted that the new pens were much better. His HbA1c at this time was 6.1% with no hypoglycaemic episodes.

Attitudes to ageing
This incident was resolved fairly easily, but it did raise a number of issues and highlighted the difficulties which the staff in nursing homes and other establishments find themselves faced with from time to time. The National Service Framework for older people (Department of Health, 2001) states, in Standard 3, that we should ‘maximise independent living’ and therefore encourage older people to be independent. However, some old people may think they are acting safely and responsibly, but in actual fact they may be putting themselves, and others, in danger. Cyril thought he could see the numbers on his pen, but in actual fact was guessing most of the time as to how much insulin he had actually dialled up.

Similarly, our expectations of other people can be powerful determinants of how we behave toward them and how they, in turn, respond to us (Harris et al, 1994). Harris and colleagues reviewed two studies and found convincing evidence to demonstrate that individuals possess negative attitudes and expectancies about older people and these attitudes may be expressed through verbal and non-verbal behaviours. The nursing staff (and I include myself here), although well-intentioned, were perhaps influenced by Cyril’s age and, as such, we expected him to be making mistakes ‘at his age’.

Misguided motives
But what does all this mean? From a nursing point of view, ensuring the safety of those in our charge is paramount, in spite of the fact that this may involve taking away a patient’s independence. This will inevitably antagonise the patient concerned. Mullins and colleagues (1998) point out that the issue of personal versus organisational control in nursing homes is an ongoing problem and Resnick (2004) seems to have hit the nail on the head when she stated that:

‘in the name of caring and doing what is best for the patient, there is a tendency to discourage self-care practices.’

Resnick goes on to say that older people may view this control as a belief that they are not capable of performing any activities including that of self-medicating. On the other hand, when family members admit their relatives to a nursing home, they have an expectation that their loved ones will be in a safe environment (Kapp, 2003). Kapp, discussing the safety of nursing homes in the USA, suggests that providers of care are afraid to be flexible when respecting the decisional rights of residents for fear of litigation and, therefore, protecting safety inevitably overrides the autonomy of patients. The focus in nursing home medical malpractice cases is on negligence (Peterson, 2002). Litigation can be triggered by anything from falls to medication errors. Preventing litigation may not always be possible, but the risks can be minimised by nurses adhering to standards, protocols and policies.

Autonomy or authority?
Nurses have multiple responsibilities, particularly where the safe administration of drugs in older adults is concerned. However, Miller (2005) suggests that nurses need to be creative in identifying safe and effective ways in assisting older adults with self-care medication. Situations like Cyril’s need sensitivity, patience and a certain degree of ingenuity. Could I have handled Cyril’s situation better than I did? Most definitely! Will a similar situation arise in the future? Without a doubt.

With the number of older people transferring to insulin therapy increasing, there will inevitably be more people who will eventually find themselves living in nursing homes. Nurses will continue to discover some older adults making mistakes with their insulin doses, yet still capable of some degree of self-care. It will be up to us, as nurses, to decide just how much autonomy each individual can cope with. 

Heath (2005) suggests that the importance of everyday nursing decisions should never be underestimated as they can have life-changing consequences for older people. Whatever Cyril was doing with his insulin seemed to be working, and working quite well. If it had not been for his untimely admission to a nursing home, his errors would probably never have come to light. No doubt when he is discharged back home, he will continue to do what he has always done without ‘interference from outside agencies’, but at least he now has improved equipment with which to do it.

Conclusion
Finally, Bonnesen and Burgess (2004) have highlighted the fact that there are so many negative messages regarding getting older. As an example, they focus attention on 40th, 50th and 60th birthday celebrations where it appears that people are mourning the loss of one’s youth rather than celebrating the length of one’s life! However, they also point out that society has been indoctrinated into stereotyping the ageing process as negative, and, therefore, the older adult is seen as having diminished capacity. While this may be true for some older people, there are many who are very capable well into their 80s.

In conclusion, Kapp (2003) suggests that, while being mindful of the safety aspect of older residents in nursing homes, safety constitutes only one important component of their lives. Kapp argues that safety does not represent the entire expectations and preferences of the older person. In acknowledging this, he calls for ‘expansive thinking and ingenuity which goes far beyond simple compliance with the safety oriented boundaries established by command and control regulations’. There are many Cyrils in the world and while the healthcare professionals are concerned with safety, let us not forget the older person’s dignity and integrity.

I was recently asked to review an older patient who was temporarily residing in a nursing home. The patient in question (Cyril) was a gentleman in his 80s – a person with bilateral amputation whose diabetes was controlled with insulin. Cyril was fiercely independent and the only reason he was in the nursing home was that his wife, his main carer, had been admitted to hospital.

When I visited Cyril the staff told me they were concerned that, due to his failing eyesight, he was not giving himself the correct doses of insulin. They had observed him on a number of occasions dialling up incorrect doses on his insulin pen. When the staff challenged him about this, he had resorted to injecting his insulin before anyone had a chance to go into his room. During our conversation, it became clear that he was a highly intelligent individual and any hint that he was not able to self-manage his diabetes was met with fierce resistance.

In fact, when I attempted to check that he was using his pen correctly and dialling the correct doses of insulin he became irate and accused us, the nursing staff, of ‘trying to trick him’. The situation was diffused by telling Cyril that his safety was our main aim and by showing him newer pens with clearer markings to which a magnifier could be attached. Cyril calmed down and accepted that the new pens were much better. His HbA1c at this time was 6.1% with no hypoglycaemic episodes.

Attitudes to ageing
This incident was resolved fairly easily, but it did raise a number of issues and highlighted the difficulties which the staff in nursing homes and other establishments find themselves faced with from time to time. The National Service Framework for older people (Department of Health, 2001) states, in Standard 3, that we should ‘maximise independent living’ and therefore encourage older people to be independent. However, some old people may think they are acting safely and responsibly, but in actual fact they may be putting themselves, and others, in danger. Cyril thought he could see the numbers on his pen, but in actual fact was guessing most of the time as to how much insulin he had actually dialled up.

Similarly, our expectations of other people can be powerful determinants of how we behave toward them and how they, in turn, respond to us (Harris et al, 1994). Harris and colleagues reviewed two studies and found convincing evidence to demonstrate that individuals possess negative attitudes and expectancies about older people and these attitudes may be expressed through verbal and non-verbal behaviours. The nursing staff (and I include myself here), although well-intentioned, were perhaps influenced by Cyril’s age and, as such, we expected him to be making mistakes ‘at his age’.

Misguided motives
But what does all this mean? From a nursing point of view, ensuring the safety of those in our charge is paramount, in spite of the fact that this may involve taking away a patient’s independence. This will inevitably antagonise the patient concerned. Mullins and colleagues (1998) point out that the issue of personal versus organisational control in nursing homes is an ongoing problem and Resnick (2004) seems to have hit the nail on the head when she stated that:

‘in the name of caring and doing what is best for the patient, there is a tendency to discourage self-care practices.’

Resnick goes on to say that older people may view this control as a belief that they are not capable of performing any activities including that of self-medicating. On the other hand, when family members admit their relatives to a nursing home, they have an expectation that their loved ones will be in a safe environment (Kapp, 2003). Kapp, discussing the safety of nursing homes in the USA, suggests that providers of care are afraid to be flexible when respecting the decisional rights of residents for fear of litigation and, therefore, protecting safety inevitably overrides the autonomy of patients. The focus in nursing home medical malpractice cases is on negligence (Peterson, 2002). Litigation can be triggered by anything from falls to medication errors. Preventing litigation may not always be possible, but the risks can be minimised by nurses adhering to standards, protocols and policies.

Autonomy or authority?
Nurses have multiple responsibilities, particularly where the safe administration of drugs in older adults is concerned. However, Miller (2005) suggests that nurses need to be creative in identifying safe and effective ways in assisting older adults with self-care medication. Situations like Cyril’s need sensitivity, patience and a certain degree of ingenuity. Could I have handled Cyril’s situation better than I did? Most definitely! Will a similar situation arise in the future? Without a doubt.

With the number of older people transferring to insulin therapy increasing, there will inevitably be more people who will eventually find themselves living in nursing homes. Nurses will continue to discover some older adults making mistakes with their insulin doses, yet still capable of some degree of self-care. It will be up to us, as nurses, to decide just how much autonomy each individual can cope with. 

Heath (2005) suggests that the importance of everyday nursing decisions should never be underestimated as they can have life-changing consequences for older people. Whatever Cyril was doing with his insulin seemed to be working, and working quite well. If it had not been for his untimely admission to a nursing home, his errors would probably never have come to light. No doubt when he is discharged back home, he will continue to do what he has always done without ‘interference from outside agencies’, but at least he now has improved equipment with which to do it.

Conclusion
Finally, Bonnesen and Burgess (2004) have highlighted the fact that there are so many negative messages regarding getting older. As an example, they focus attention on 40th, 50th and 60th birthday celebrations where it appears that people are mourning the loss of one’s youth rather than celebrating the length of one’s life! However, they also point out that society has been indoctrinated into stereotyping the ageing process as negative, and, therefore, the older adult is seen as having diminished capacity. While this may be true for some older people, there are many who are very capable well into their 80s.

In conclusion, Kapp (2003) suggests that, while being mindful of the safety aspect of older residents in nursing homes, safety constitutes only one important component of their lives. Kapp argues that safety does not represent the entire expectations and preferences of the older person. In acknowledging this, he calls for ‘expansive thinking and ingenuity which goes far beyond simple compliance with the safety oriented boundaries established by command and control regulations’. There are many Cyrils in the world and while the healthcare professionals are concerned with safety, let us not forget the older person’s dignity and integrity.

REFERENCES:

Bonnesen JL, Burgess EO (2004) Senior moments: The acceptability of an ageist phrase. Journal of Aging Studies 18(2): 123–142
Department of Health (DoH; 2001) National Service Framework for older people. DoH, London. Available at http://www.dh.gov.uk/assetRoot/04/07/12/83/04071283.pdf (accessed 06.12.2005)
Harris MJ, Moniz AJ, Sowards BA, Krane K (1994) Mediation of interpersonal expectancy effects: expectancies about the elderly. Social Psychology Quarterly
57(1): 36–48
Heath H (2005) Every day actions shape future directions. Nursing Older People
17(3): 3
Kapp MB (2003) ‘At least mom will be safe there’: the role of resident safety in nursing home quality. Quality & Safety in Health Care
12(3): 201–4
Miller CA (2005) Drugs and the elderly: looking back and ahead. Geriatric Nursing
26(1): 60–1
Mullins LC, Moody L, Colquitt R, Mattiasson A-C, Andersson L (1998) An examination of nursing home personnel’s perceptions of residents’ autonomy. Journal of Applied Gerontology
17(4): 442–61
Peterson AM (2002) Overview of the nursing home litigation process. Geriatric Nursing
23(1): 37–42
Resnick B (2004) Research review: self-administration of medication in hospital: patients’ perspectives. Geriatric Nursing
25(5): 309–10

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