Abstract
There is increasing interest in harnessing aged care residents’ perspectives to drive quality improvement in aged care homes. We conducted a systematic review of qualitative evidence including literature examining residents’ descriptions of “quality of care” in aged care homes, using database searches and screening records according to eligibility criteria. Three independent reviewers conducted quality assessment of forty-six eligible articles and performed thematic synthesis of articles’ findings. We distinguish nine key themes describing factors influencing quality care: staffing levels, staff attitude, continuity, routine, environment, decision-making and choice, dignity of risk, activities, and culture and spirituality. While many themes were consistent across studies, residents’ prioritization of them varied. Aged care home residents have differing conceptions of quality care as well as heterogeneous and dynamic needs and preferences. Care providers are best able to facilitate quality care when intentional efforts are made to recognize this and tailor delivery of services the individual residents.
Keywords
Introduction
Ensuring quality of care in aged care homes is a politically important topic internationally. In January 2019, the Australian Federal government launched a Royal Commission into Aged Care Quality and Safety after an investigative report by Australia’s state-owned television broadcaster revealed extensive cases of abuse, neglect, and failure of care in residential aged care facilities (Royal Commission into Aged Care Quality and Safety, 2019). This was just the latest in a long line of media scandals exposing poor quality care in aged care homes, both in Australia and other countries (Miller et al., 2012). More recently, the impact of COVID-19 on care homes worldwide has publicized ongoing problems with staffing, regulation, commercialization, and healthcare integration, further fueling calls for quality-oriented reforms (Darbyshire & Dyer, 2020; Davidson & Szanton, 2020).
Yet, defining quality of care is a challenging task. Appropriate quality measures differ depending on one’s position in the system, resources, and purpose of investigation (Castle & Ferguson, 2010; Donabedian, 1988; Kane, 2003; O’Reilly et al., 2007). There is consensus that while clinical quality indicators are useful (which in Australia involve mandatory monitoring of pressure injuries, physical restraint, and unplanned weight loss), such measures do not capture how residents experience care, and the influence of care on well-being and quality of life (Armstrong, 2018). Some survey measures, which aim to elicit information about aged care residents’ lived experiences, preferences, and quality of life, have allowed expansion of quality indicators to better incorporate residents’ perspectives (Courtney et al., 2003; Kane et al., 2003). Yet, a limitation of surveys is that they inevitably involve assumptions about what participants consider important, and therefore need to be carefully selected based on the target population (Aspden et al., 2014).
Qualitative research can make an important contribution to understanding residents’ views on quality care. While no research can be entirely inductive (Paley, 2017), qualitative interviews afford participants space to reflect upon questions using their own words, and to describe their expectations and explanations about what is important to them (Bradshaw et al., 2012; Kvale, 2007). They invite participants to explain how the structures and processes of care either support or diminish quality of life and well-being. By illustrating which aspects of care are generally important to residents, qualitative findings can inform the refinement of quality measures, person-centered practices and policies, and aged care regulation (Aspden et al., 2014).
Qualitative methods have been increasingly used to document aged care residents’ perspectives over the last two decades (Bradshaw et al., 2012; Vaismoradi et al., 2016). This is due to a normative and regulatory shift toward person-centered care practices (Braithwaite et al., 2007; Brownie & Nancarrow, 2013), a greater emphasis on consumer experiences in quality assessment (Castle & Ferguson, 2010; Kane, 2003), as well as being a way to envisage and co-design innovative care models and environments (Bowers et al., 2001; Heid et al., 2016; Potter et al., 2018; van Steenwinkel et al., 2017). This study aims locate and synthesize existing qualitative studies of aged care residents’ perspectives on quality of care in aged care homes. To capture these perspectives, we operationalized “quality of care” in a flexible way, to encompass how both instrumental and interpersonal care practices, and how structural and processual factors, relate to quality outcomes from residents’ points of view (Castle & Ferguson, 2010; Donabedian, 1988; Kajonius & Kazemi, 2016).
Method
We undertook a systematic review of qualitative evidence (Lockwood et al., 2017) following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009). We then performed a thematic synthesis of included studies (Thomas & Harden, 2008). To aid data extraction and analysis, we operationalized “quality of care” by loosely drawing on Donabedian (1988), who argues that “quality of care” is facilitated by structures (e.g. environment, staffing, resources) and processes (e.g. care practices, organization policies) to produce desired outcomes (e.g. quality of life, well-being, rehabilitation, physical health).
Literature Search
Articles were eligible for inclusion if they were (i) full-text articles, (ii) published in English, (iii) published in a peer-reviewed journal, (iv) published after 1 January 2009, (v) reporting on original qualitative empirical data, (vi) had participants who were permanent residents of aged care/long-term nursing facilities, and (vii) produced substantial evidence about residents’ perspectives on quality of care. Studies were excluded that involved only aged care staff or family perspectives on quality of care, as well as studies without substantial qualitative data. We excluded studies set exclusively in service-integrated housing, or similar models where residents have lower dependency on care staff. We also excluded any studies that evaluated quality indicators, interventions, or policies, if they did not produce substantial qualitative evidence of residents’ perspectives on quality of care. Finally, we excluded some studies conducted in contexts vastly different to the others, such as some from developing non-Western countries, as these produced findings too divergent from key themes to permit synthetic analysis (Bradshaw et al., 2012; Thomas & Harden, 2008). We chose 1 January 2009 as the publication start-point to correspond with the cut-off point of another similar review (Bradshaw et al., 2012), and all databases were searched on 9 September 2020. We searched four databases, PubMed, PsychInfo, Web of Science and Scopus, and developed and adapted our search terms for each database. Details on the search strategy are included as supplementary material.
Screening
Four reviewers (AG, SG, LK, and BD) screened titles and abstracts for relevance using Covidence, a web-based systematic review platform. Two votes were required for inclusion, and conflicts were resolved by a third vote. Three reviewers (AG, SG, and LK) assessed remaining full-text articles for eligibility, with disagreements resolved by consensus (see Figure 1). 46 articles were found eligible. Article quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research (Lockwood et al., 2017). To determine the article credibility, we categorized 10 “Yes” scores as Unequivocal, 5–9 as Credible, and below 5 as Unsupported. Sixteen articles scored Unequivocal, suggesting highest methodological quality. One article scored Unsupported, but we still extracted quotations by the study’s participants.
PRISMA flow diagram.
Data Analysis
We extracted article details into bespoke data extraction forms. Extracted data included quotations from study participants or authors’ paraphrasing of participant responses. Our aim was to review how residents described “quality of care,” but most included studies did not address this specifically. Drawing on Donabedian (1988), we analyzed how residents described relations between structures, processes, and outcomes. We treated this analysis as evidence of residents’ perspectives on “quality of care.” For example, many included studies focused on outcomes such as “quality of life,” “living well,” or “a good life.” In such cases, we examined how these outcomes were attributed to structures and processes of aged care homes. Where outcomes were not attributed to anything or attributed to “external” factors such as family history, personality type, or health events prior to admission (Castle & Ferguson, 2010), those data were not extracted.
Data extraction forms were imported into NVivo 12 (QSR International) by AG. Forms were coded in vivo, and codes were then iteratively grouped, ungrouped, and revised. Authors (AG, SG and LK) then met to discuss the coding and agreed on nine key themes that succinctly and accurately synthesized included studies’ findings.
Summary of Included Studies.
Results
Forty-six studies from 18 countries were eligible, with one multi-country study. There was high representation from Australia, USA, Norway and Netherlands among the included studies. Most studies involved semi-structured interviews with residents. Four studies involved focus groups and two were observations of resident meetings. Most studies involved thematic analysis, with some others applying grounded theory, variants of phenomenological or hermeneutic analysis, or other analytic approaches. Despite this, most studies presented findings in a similar way, as themes organized under subheadings, with discussion sections that drew broader generalizations. Our thematic synthesis is grouped into nine themes, presented under corresponding subheadings, below: staffing levels, staff attitude, continuity, routine, environment, decision-making and choice, dignity of risk, activities, and culture and spirituality. All quotations are by care home residents who participated in the included studies.
Staffing Levels
Many studies cited inadequate staffing as a factor influencing quality of care. Residents often said there were insufficient staff numbers (Bollig et al., 2016; Donnelly & MacEntee, 2016; Hasegawa & Ota, 2019) and staff had insufficient time (Dybvik et al., 2014; Harrison & Frampton, 2017; Moyle et al., 2011; Nakrem et al., 2011, 2013; Palacios-Ceña et al., 2013). Staffing factors were perceived to impact staff’s ability to perform their work to a high standard. You know, they [the other residents] are placed in a chair and then they sit there. With more personnel, we could come out more often…and not just sit in a chair in the living room and be half asleep. (quotation in Bollig et al., 2016, p. 149) They don’t have enough nurses to get you up to go to the toilet, so they put these things on you…so you have to put up with something…it was hard…and I said “couldn’t we have a bedpan?” Well, [chuckles uncomfortably] I’ve got them the odd time, but not very often. Well, now I’m used to it. (quotation in Donnelly & MacEntee, 2016, p. 154)
Staff Attitude
Staff attitude strongly influenced residents’ perceptions of quality of care. However, both across and within the studies there were differing opinions about what kind of attitude was appropriate. Most often, a “good attitude” referred to compassion and kindness in interpersonal interactions (Adra et al., 2015; Bangerter et al., 2016; Boelsma et al., 2014; Bollig et al., 2016; Donnelly & MacEntee, 2016; Dybvik et al., 2014; Johs-Artisensi et al., 2020; Rodríguez-Martín et al., 2013), and receptivity to residents when speaking up about their needs and wishes (Dybvik et al., 2014; Harrison & Frampton, 2017; Nakrem et al., 2013). They are friends of ours [staff] and they treat us like that, they’re company and they don’t just take the sheets off and clean up and take off again, they stop and stay here for 10 or 15 minutes. (quotation in Walker & Paliadelis, 2016, p. E8)
Poor attitude was associated with staff who avoided taking responsibility for residents’ needs (Dybvik et al., 2014; Harrison & Frampton, 2017), treated residents like children (Donnelly & MacEntee, 2016), or lacked enthusiasm for their work (Donnelly & MacEntee, 2016). A resident in one study suggested staff are more likely to neglect residents with dementia or other disabilities that impede self-advocacy (Kang et al., 2020).
Continuity
Residents often expressed a preference for familiar staff, who understood their needs and preferences well and offered continuity of care. Residents attributed lack of continuity to poor working conditions and high staff turnover in care homes (Cook et al., 2015; Kang et al., 2020; Rodriguez-Martin et al., 2013). When residents knew staff well, they felt they were more likely to be treated with respect and dignity (Drageset et al., 2017; Oosterveld-Vlug et al., 2013), were better able to share personal information and stories (Nakrem et al., 2011), and received a higher standard of care (Heid et al., 2016; Johs-Artisensi et al., 2020; Mjorud et al., 2017; Oosterveld-Vlug et al., 2013). Coming to know and trust members of the care staff team was important in many residents’ adaption to the change of environment and loss of autonomy associated with aged care (Bollig et al., 2016; Nakrem et al., 2011; van Hoof et al., 2016). Some residents said they valued friendships with staff (Rodríguez-Martín et al., 2013), especially those residents without family or friends outside the care home (Moyle et al., 2015). [F]riendship between health care workers and residents…has been very good…absolutely. Friendship—being on the same frequency with your caregiver—the feeling that he or she respects you, recognizes your self-worth, and likes you as a person…this is true kindness. (quotation in Drageset et al., 2017, p. 4) They treat you with respect. They do now, but not at the start because you hadn’t been around so long. If there’s something I want now, they will consider it or discuss it. Before, they would’ve said no straight away. They don’t care two hoots about you. That has got better over time, them respecting your wishes. For example, how I want to be washed, the fact that I don’t always want to take a shower…that I don’t always want to eat in the dining room. (quotation in Oosterveld-Vlug et al., 2013, p. 5)
Routine
Residents in many studies expressed dissatisfaction with the way routines were uniformly applied to all residents, with little consideration of their individual preferences or needs (Donnelly & MacEntee, 2016; Hasegawa & Ota, 2019; Wang et al., 2016). At times, it seems they move us like furniture. They’re all rushing, non-stop…They must satisfy their timetable needs; therefore, if they have to take everybody for breakfast, they do so. (quotation in Palacios-Ceña et al., 2013, p. 1048)
Residents in some studies adjusted well to routines. These residents spoke positively about their daily lives being structured in regular and predictable ways, as it meant they knew what to expect and it enhanced their feeling of being safe and cared for (Cooney, 2012; Minney & Ranzijn, 2016; Moyle et al., 2015; Palacios-Ceña et al., 2013; Wang et al., 2016). You go to bed, and then they look in on you and say, “So you are in bed now?” Then, you know that two nurses are working the night shift and that you are safe…So I do feel safe staying in a nursing home. (quotation in Dybvik et al., 2014, p. 539)
Environment
Residents consistently referred to the built environment as an integral indicator of good quality of care. Privacy was important, and residents with private rooms stated that they enjoyed having control over the space, and valued the ability to populate rooms with personal possessions (Cook et al., 2015; Cooney, 2012; Molony et al., 2011; Motteran et al., 2016; van Hoof et al., 2015). I feel good in my room because it’s my room, I’m always sorting it out as I want it…I put my things in their right places…later, when I go out, I check if everything’s in order…“there”…it makes me feel good. (quotation in Motteran et al., 2016, p. 156) I don’t have a key that I can lock my door. I have to sit and watch where I am. I sit just down the road there, just outside there, so I can watch me door when people come in out and that…I haven’t got a key for my door, which I would like to have. (quotation in Milte et al., 2016, p. 12)
Residents valued freedom of movement and easy access to outdoor settings (Molony et al., 2011; van Hoof et al., 2015). Residents also valued the environment being quiet and clean (Chuang et al., 2015; Milte et al., 2016; Rodríguez-Martín et al., 2013). A tranquil, peaceful physical environment signified that “all is well,” whereas a noisy or disruptive environment signified distress and unmet needs (Stewart-Archer et al., 2016; van Hoof et al., 2015).
Decision Making and Choice
Overall, residents valued the ability to self-determine and to make decisions around their own care and treatments without being dependent on family or staff proxies (Bangerter et al., 2016; Boelsma et al., 2014; Cooney, 2012; Cook et al., 2015; Nakrem et al., 2011). Being able to make decisions and show independence supported residents’ adjustment and helped avoid feelings of helplessness (Heid et al., 2016; Stewart-Archer et al., 2016). In addition, choice was appreciated regarding food and social interactions (Abbott et al., 2018; Milte et al., 2017). Residents identified being able to express preferences for certain foods, as well as having input into food options, as being key components of good quality care (Abbott et al., 2018; Milte et al., 2017). Quality care was also associated with having freedom of movement (Potter et al., 2018; van Hoof et al., 2016), the ability to go out when desired (Cho et al., 2017; van Steenwinkel et al., 2017), and having flexibility in one’s daily schedule (Johs-Artisensi et al., 2020; Milte et al., 2016). You lose a big part of your freedom. Everybody who comes into a nursing home will discover that. For example, you cannot just take your bag and tell them that you will go shopping. You cannot do that. (quotation in Bollig et al., 2016, p. 148)
By contrast, being unable to make decisions made many residents dissatisfied: Sometimes we are forced, yeah. The staff want to have their way with so many things. Like with the curtains, so much fuss. They have to open them but then my eyes start to sting. They even get involved with my few possessions. There should be more attention given to complaints, they should give more consideration to what I want, not just pay lip-service. (quotation in Nakrem et al., 2011, p. 221)
Dignity of risk
Residents reported a conflict between the obligation staff members felt to protect residents from exposure to risks and their own desire to undertake potentially risky activities. Some said they were prevented from undertaking activities such as shopping, gardening, and walking alone by risk-averse staff, and that this denied them choice and negatively impacted their quality of life. All my life I have had a vegetable garden, I like feeling the earth between my fingers, watching the plants grow…At this home, I can’t do this because the gardening tools are considered to be a risk. They force me to go to the gym, dance or watch television. (quotation in Palacios-Ceña et al., 2013, p. 113) I spend my day pacing the cage like an animal. I haven’t been outside in over 6 months because they don’t have time. They think I will run away and they will get sued. It would be cruel to keep a dog in a cage this long, but not an old man. (Harrison & Frampton, 2017, p. 10)
Activities
While activities can promote engagement and satisfaction in care homes, merely providing activities does not ensure quality of care (Popham & Orrell, 2012). Many residents wished to engage in activities that aligned with their own personal preferences (Johs-Artisensi et al., 2020; Milte et al., 2016; Stewart-Archer et al., 2016; Walker & Paliadelis, 2016), especially those related to hobbies and interests from their past life (Adra et al., 2015; Cahill & Diaz-Ponce, 2011; Dybvik et al., 2014; Milte et al., 2016; Slettebo et al., 2017; Stewart-Archer et al., 2016). As one resident put it, “doing things that I like, not necessarily what others care for” (quotation in Stewart-Archer et al., 2016, p. 1723). Meaningful activities like volunteering and assisting with routine tasks within the facility were also looked upon favorably, as they fostered a sense of purpose (Abbott et al., 2018; Johs-Artisensi, 2020; Palacios-Ceña et al., 2016). In contrast, activities that were standardized and diversional, such as watching TV or bingo, were not always valued and sometimes associated with low quality care (Milte et al., 2016; Moyle et al., 2015). Regardless of the type of activity provided, residents often commented on the social value of activities in promoting connections within the resident community (Adra et al., 2015; Cook et al. 2015; Cooney, 2012; Drageset et al., 2017; John-Artisensi et al., 2020; Kang et al., 2020; Minney & Ranzijn, 2016; Moyle et al., 2011; Nakrem et al., 2013; van Hoof et al., 2016; van Zadelhoff et al., 2011). [T]he fact that [the health care workers] arrange a variety of activities you can attend and meet other people…is very positive, with music and exercise for example…and to be able to join in. (quotation in Drageset et al., 2017, p. 5)
Solitary activities were important to some residents (Palacios-Ceña et al., 2016; Stewart-Archer et al., 2016), as they ensured those who preferred not to socialize were still able to participate in meaningful pursuits that met their interests. Overall, residents generally wished to exercise choice over the terms of their participation in activities. Having their decisions recognized and respected was conducive to quality care (Harrison & Frampton, 2017; Moyle et al., 2015; Slettebo et al., 2017).
Culture and spirituality
Maintaining and practicing cultural and spiritual beliefs was important for many residents (Adra et al., 2015; Garcia-Javier & Dayap-Latosa, 2015; Hughes & Moore, 2012; Minney & Ranzijn, 2016; Moyle et al., 2015), especially members of ethnic or religious minorities (Abbott et al., 2018; Wang et al., 2016). It was important for some residents that care homes provide culturally appropriate lifestyle options, such as specific foods and mealtime practices (Adra et al., 2015; Cho et al., 2017; Chuang et al., 2015). Religion was for many residents a source of comfort as well as a way of creating meaning in life and maintaining identity (Adra et al., 2015; Bangerter et al., 2016; Drageset et al., 2017). Yet there were often barriers to fulfilling spiritual needs, especially when residents were unable to attend external religious services (Abbott et al., 2018; Chuang et al., 2015; Wang et al., 2016). Can’t do it, I am Ukrainian orthodox and they don’t have those types of services. The religion is close but not exactly. In order to go to Ukrainian orthodox services, then I would need transportation. Since transportation is an issue, I have to accept what is here. (quotation in Abbott et al., 2018, p. 1129) I am a Buddhist…It is hard to worship now, but I think about it in my mind. (quotation in Chuang et al., 2015, p. 47)
Discussion
Consistent with other studies (Bowers et al., 2001; Bradshaw et al., 2012; Vaismoradi et al., 2016) our thematic synthesis suggests that aged care residents have differing understandings of “quality care” in residential aged care settings, which encompass multiple interrelated factors and depend on their individual situation and needs. Drawing loosely on Donabedian’s concept of “quality of care” we identified both structural (staffing levels, environment) and processual (staff attitude, routines, decision-making and choice, activities) dimensions, as well as elements (e.g. continuity, dignity of risk, and culturally appropriate care) which may be better described as outcomes.
Previous reviews by Bradshaw et al. (2012) and Vaismoradi et al. (2016) described the importance of residents’ acceptance of and adjustment to their situation in residential aged care as a factor affecting quality of life. As we focused on quality of care, we focused less on psychological adjustment processes and more on the structural and processual factors that may facilitate residents’ acceptance and adjustment. These include a home-like environment, continuity of care, and having choices about living options, routines and activities. The desire to make informed decisions was a salient issue, encompassing decisions about medication and treatments, access to outdoors or the community, daily routines, diet and mealtimes, and activities. This accords with literature arguing that there has been a generational shift toward consumerist rather than paternalistic expectations of aged care, with an emphasis on enablement and choice rather than safety and protection (Armstrong, 2018; Bowers et al., 2001; Bradshaw et al., 2012; Kane et al., 2003; Popham & Orrell, 2012).
Our review also shows that different residents may have different expectations of care, and different criteria for evaluating “quality” (Bowers et al., 2001). Molony et al. (2011) interviewed residents transferring between traditional nursing homes and supported housing designed for independent living. They found that while some residents welcomed more freedom to define their own routines and contribute to the running of the facility, others equated this independence with lower quality care because it meant staff were less attentive and expected more self-care from residents than in a care home. Thus, decision-making is not synonymous with independence, as residents may opt for living situations that afford them less independence. Findings like this suggest that “quality of care” is not just about how direct care staff practice both clinical and interpersonal care, but also encompasses the antecedents of these practices, where residents are first matched with the right care models or care environments to best accommodate their individual preferences, capacities and needs.
Bradshaw et al. (2012) argue that aged care residents desire a relationship-centered approach to care that values familiarity and friendship between staff and residents rather than conceiving of quality of care in purely clinical terms. Our findings partially support this. However, not all residents in the reviewed studies saw relationship-centered care as a priority or even as desirable. Bowers et al. (2001) distinguished between care as relationship-, consumerist-, and comfort-focused, with different residents placing a higher priority on one focus over the others. In this sense, quality is not synonymous with any one of these three foci but relates to how aged care providers and aged care staff identify what is most important to each resident. As Heid et al. (2016) demonstrate, residents’ needs and preferences are likely to fluctuate for a variety of reasons, including physical and mental health, mood, relationships with others, and finances. A person-centered approach to care means tailoring care to residents in a continual and iterative process (Brownie & Nancarrow, 2013). This requires organizational structures and processes that facilitate active monitoring of and communication with residents (Abbott et al., 2018; Heid et al., 2016). Furthermore, our findings suggest insufficient staffing levels, lack of training, or high turnover inhibit the capacity of staff to offer personalized care.
Methodological Issues
We used the ten-point Joanna Briggs Institute Critical Appraisal Checklist for article quality evaluation. However, the appropriateness of using checklists to evaluate qualitative research has been variously disputed (Lockwood et al., 2015; Mays & Pope, 2000). We found difficulties accounting for terminological inconsistencies and cursory explanations of methods in some studies. Some studies with unclear methods satisfied most checklist criteria, while some that were methodologically outstanding (e.g. Abbott et al., 2018) did not satisfy all criteria and appear as Credible. This should be considered when interpreting credibility ratings in Table 1.
Only 18 of the 46 included studies documented the ethnicity of participants. Most others involved a majority of white European participants, and four reported from Asian contexts. Given past research has shown experiences and perceptions of quality of care may be influenced by ethnicity and race (Mor et al., 2004), more qualitative research into possible discrepancies in the way different ethnic groups experience aged care is needed.
Most studies had under 25 participants, with as few as six. This is typical of qualitative research, which does not claim statistical generalizability. Nonetheless, the thematic consistency we found across the 46 studies does suggest “analytical generalizability” (Phoenix, 2018; Polit & Beck, 2010), insofar as our thematic synthesis illustrates commonalities to residents’ perspectives despite a wide range of different facility types and contexts.
Limitations of this Review
Not all studies specifically explore aged care residents’ understandings of quality of care, and in some studies “quality of care” and “quality of life” were presented as conflicting care priorities (e.g. Hughes & Moore, 2012). This meant we translated other findings into our own operationalization of “quality of care.” It can be argued that this distorts findings of other studies by removing them from their particular context and using terms their authors may have purposely avoided (Thomas & Harden, 2008). Our “thematic synthesis” required us to compress specific topics, such as quality of food and staff-family relations, into broader, more abstract themes, thus losing some of the specificity expressed by individual residents. For this reason, as well as discrepant sample sizes, we could not rank the relative importance of themes.
This review included studies set in “nursing homes,” broadly defined, and excluded studies set exclusively in other long-term care models, such as independent units or supported housing. We recognize there are international differences in definitions of these models, which could lead to ambiguity in applying our eligibility criteria (Armstrong, 2018; Robison et al., 2011). Also, the meaning of “quality of care” varies internationally. In US and Canadian regulation, it refers primarily to clinical care, whereas in much European and Australian regulation it also encapsulates social and environmental aspects of care (Armstrong, 2018; Braithwaite et al., 2007). Our thematic synthesis suggests residents’ views on “quality of care” align more closely with the latter conceptualization. These and other international differences, including the integration of aged care and healthcare systems (Armstrong, 2018), patterns of ownership and governance (Harrington et al., 2017), or “regulatory styles” (Braithwaite et al., 2007), may influence residents’ perspectives on quality care. Our synthesis of themes across studies prevented comparative analysis of international differences.
We excluded studies on the perspectives of younger (under 65 years old) residents in aged care after determining this population has different life experiences and understandings of “quality care,” making synthesis with other studies difficult. We included studies on perspectives of people with cognitive impairment or dementia, as they constitute a large proportion of care home residents (around 50% in Australia), and integral to understanding residents’ perspectives (Australian Institute of Health and Welfare, 2018). We did not provide detailed investigation of differences between people with dementia and other aged care residents, as people with dementia were less represented in the data, and some studies did not clearly identify which participants had dementia. We also recognize that staff and family members provide valuable insights into quality of aged care but did not review them here.
Conclusion
A generational shift toward models of residential aged care that are more consumer-centric and responsive to residents’ needs means that residents’ own perspectives on quality of care constitute a valuable resource for evaluating services and driving innovations. This paper reviews the last 10 years of qualitative evidence on what aged care residents perceive is quality care. Consistent with previous reviews (Bradshaw et al., 2012; Vaismoradi et al., 2016), we find that quality care has multidimensional meanings to aged care residents. What constitutes “quality” to residents depends partly on factors that are prone to change over time. Organizational policies best support quality care when they actively enable monitoring of and communication with residents to keep abreast of changes in needs and preferences. Quality therefore depends on aged care providers and staff identifying what is most important to each resident and tailoring the delivery of services to them.
Supplemental Material
Supplemental Material, supplementary_materiala - Aged Care Residents’ Perspectives on Quality of Care in Care Homes: A Systematic Review of Qualitative Evidence
Supplemental Material, supplementary_materiala for Aged Care Residents’ Perspectives on Quality of Care in Care Homes: A Systematic Review of Qualitative Evidence by Andrew S. Gilbert, Stephanie M. Garratt, Leona Kosowicz, Joan Ostaszkiewicz and Briony Dow in Research on Aging
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by funding from the Victorian Government, Department of Health and Human Services.
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References
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