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Centre for Health Services Studies

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

Jenny Billings, Research Fellow

Commissioned by East Kent Coastal PCT

Centre for Health Services Studies www.kent.ac.uk/chss 2

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


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


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)


Operational Definitions

• Age discrimination happens when someone makes or sees a distinction because of another person’s 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)


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


Method - sample

• Purposeful recruitment, diversity encouraged• 57 participants

• Community 51% (n=29)• Nurses (specialist, DNs, practice and mental health),

GPs, GP practice staff, CART and Rapid response

• Acute hospital 36% (n=21)• Nurses (specialist, general and mental health), physios,

OTs, social workers, administration

• Other groups 13% (n=7)• Voluntary services (Red Cross and Age Concern), health

promotion, education


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


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


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


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


Findings – Access to Services

• Most statement ‘rarely’ or ‘never’ witnessed

• Access to specialist services denied – ‘persuasion’ tactics “Go home and stop worrying about it” (1:p2) – 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 65’s.


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


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


Findings – Treatment and Care

• Difficulties addressing sexuality – ‘no sex please, we’re 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


The Role of Relatives

• Requesting for older person to stay in hospital longer

• Questioning the need for treatment “Is it worth it? Can’t you let him be?” (2:p2)

• Demanding services, especially at weekends “Weekend relatives syndrome” (6:p3) – judgements become confused with guilt

• Seeming to act on the older person’s behalf


Discussion

• Client centred care

• Clinical priorities and standards

• The role of relatives


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


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)


The Role of the Relatives

• Highly emotionally charged situation• Burden of caring (Carer’s 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)


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


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


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


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

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www.kent.ac.uk/chss centre for health services studies staff perceptions of ageist practice in the...

Documents

practice slide

mental health

specialist services

literature health

health promotion

age discriminatory practice

age concern

age tinker