Staff Perceptions of Ageist Practice in the Clinical Setting: Practice Development Project

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Staff Perceptions of Ageist Practice in the
Clinical Setting Practice Development Project

• Jenny Billings, Research Fellow
• Commissioned by East Kent Coastal PCT

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Aims of the Study

• Identify and describe the nature of any age
  discriminatory practice in the clinical setting
  through the perceptions and experiences of staff
  working with older people in East Kent
• Provide recommendations for practice

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Background

• Linked to the audit of NSF for Older People
  Standard 1 Rooting out discrimination (DoH
  2001)
• Initial audit of policy documents highlighted the
  complexity of age discrimination issues (DoH
  2002)
• Ageism difficult to combat as based on
  internalised perceptions, often invisible and
  unchallenged
• Lack of common definition or understanding
• Difficult to identify and tackle and no concrete
  solutions
• Recommended series of actions areas including
  workforce development and ascertaining staff
  perceptions

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Literature

• Health and social care discussion papers
• Rationing by age for (Williams 1997) and against
  (Rivlin 1995)
• Quality of care and age discrimination (Ellis
  2002)
• Resuscitation and ageism (Rosenfeld et al 1997)
• Empirical research
• Ageism in access to specialist services such
  cardiology (Bowling et al 1999) and
  transplantation (Varekamp et al 1998)
• Exclusion of older people from clinical trials
  (Bayer 2000)
• NHS and social care managers struggle to tackle
  ageism (Roberts et al 2002)

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Operational Definitions

• Age discrimination happens when someone makes or
  sees a distinction because of another persons
  age and uses this as a basis for prejudice
  against, or unfair treatment of that person (DoH
  2001)
• Ageist practice refers to the carrying out of
  unfair or insensitive treatment because of age
  (Tinker 1996)

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Methods study design

• Largely qualitative approach using focus groups
  design (Morgan 1997, Kitzinger 2000)
• Six focus groups conducted across East Kent
  between October 2002 and March 2003
• Initial interview schedule discussion areas
• Access to services
• Communication
• Attitude
• Privacy and dignity
• Personal care
• Treatment

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Method - sample

• Purposeful recruitment, diversity encouraged
• 57 participants
• Community 51 (n29)
• Nurses (specialist, DNs, practice and mental
  health), GPs, GP practice staff, CART and Rapid
  response
• Acute hospital 36 (n21)
• Nurses (specialist, general and mental health),
  physios, OTs, social workers, administration
• Other groups 13 (n7)
• Voluntary services (Red Cross and Age Concern),
  health promotion, education

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Methods data collection

• Recent experiences of ageist practice that
  participants had
• Seen or heard in the care setting
• Heard via an older service user or carer
• Read about in medical notes
• Gain consensus views of experiences
• Rival explanations
• Participant reference sheet (Kitzinger 2000)
• Development of discussion tool after first two
  groups
• Recording the discussion - flip chart and notes

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Discussion Tool

• Consensus view of statements of experiences
  developed after first two focus groups
• Three sections
• Access to services
• Communication and attitude
• Treatment and care
• Five dimension rating scale often to never
  and N/A
• Addition of two statements - access and clinical
  trials

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Data Analysis

• Simple descriptive statistics of discussion tool
• Content analysis of qualitative data using
  pre-determined template (Flick 1998)
• Access to services
• Communication and attitudes
• Treatment and care
• Additional open-coding system

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Ethical Issues

• NSF Audit framework and service development
• Full explanation given
• Consent obtained
• Confidentiality stressed
• Ground rules established
• Could withdraw selves or comments at any time

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Findings Access to Services

• Most statement rarely or never witnessed
• Access to specialist services denied
  persuasion tactics Go home and stop worrying
  about it (1p2) does doctor know best?
• Age restriction and competition experienced with
  access to neurology units and ITU misunderstood
  as policy
• Perception of low priority that compromises care
  medical attention, surgery, phlebotomy
• Poor access to mental health beds and no
  community support team for over 65s.

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Findings Communication and Attitude

• More than half witnessed insensitive treatment
  often or sometimes - could occur across all
  age groups but more likely with older people
• Inappropriate address
• Exclusion of older people from discussions
• Some labelling (mildly demented), but improving
• All more common among visiting staff

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Communication and Attitudes cont Information
giving

• Would not understand or not bothered
• Tell relatives first
• Too much information frightening, difficulties
  interpreting information.. but more silver
  surfers
• Older people do not want to know about their
  condition
• Need to translate information

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Findings Treatment and Care

• Difficulties addressing sexuality no sex
  please, were old, embarrassment, gender issues,
  professional inexperience
• Client involvement in resuscitation very
  difficult
• Poor assessment, especially client input at joint
  assessments
• Issues of safe medication
• Resources lack of staff related to poor quality
  of care and choice
• Hard to make clear clinical decisions in complex
  cases

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The Role of Relatives

• Requesting for older person to stay in hospital
  longer
• Questioning the need for treatment Is it worth
  it? Cant you let him be? (2p2)
• Demanding services, especially at weekends
  Weekend relatives syndrome (6p3) judgements
  become confused with guilt
• Seeming to act on the older persons behalf

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Discussion

• Client centred care
• Clinical priorities and standards
• The role of relatives

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Client Centred Care

• Engaging older people in their care
• The desire, but not the ability (Hamalainen et al
  2002)
• Care choices not always discussed (Tinker 1995)
• Professional take-over
• Accede to doctors decisions and become inactive
  - doctor knows best
• Professionals making assumptions can be caring
  but often insensitive
• Policy perspective (Ham Alberti 2002)
• Historical power imbalance between doctor and
  patient
• New patient involvement policy not internalised

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Clinical Priorities and Standards

• How are priorities decided?
• Misunderstood protocols become common practice
• Link to resources and rationing (Grimley Evans
  1997)
• Bowling et al (1992) ceding your place on the
  waiting list
• A diminishing trend? Baby boomers may rebel!
• Making clinical judgements
• Difficulties defining clear clinical standards in
  complex cases, information giving and assessing
  sexuality
• Confusing guidance resuscitation guidelines
  openness and transparency, whilst maintaining
  sensitively and inclusiveness (BMA 2001)

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The Role of the Relatives

• Highly emotionally charged situation
• Burden of caring (Carers UK 2002)
• Home care seen as less secure option
• Feelings of guilt
• Relationship with professionals
• Difficulties starting a conversation and getting
  information (Laitinen Isola 1996)
• Seen as overly demanding or ignored (Henwood
  1998)
• Competence not recognised (May et al 2001)

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Conclusion

• A wide diversity of issues leading to attachment
  of ageist label in some circumstances
• Complex and inter-related factors no simple
  manifestation, so no straightforward answer
• Hints of wider societal attitude need a long
  term approach
• Influencing themes
• Expectations and behaviour of older people
  themselves
• Impact of staff attitudes and behaviours
  assumptions
• Influence of organisational systems
  institutional ageism
• The circumstances and perceptions of relatives
  and carers

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Recommendations Role of the Commissioners

• Clear position on ageism setting the agenda
• Influencing the environment planning and
  allocation of services
• Communicating clear and explicit values to help
  shape the service users expectations

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Recommendations Programme Development

• Development and communication of standards and
  values with users what should be expected?
• Training and education using effective models
• Review of organisational systems from client
  perspective
• Review of engagement processes
• Lateral learning from parallel situations eg.
  MacPherson inquiry (Stephen Lawrence)
• Piloting and evaluating new developments

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Limitations

• Subjective view based on perceptions, but truly
  quantifiable consensus could not be reached
• Not generalisable, but themes have analytical
  generalisation and gains credibility through
  detail and local application
• No views from users and carers

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Centre for Health Services Studies

• www.kent.ac.uk/chss