This comprehensive research article, titled “Staff members’ prioritisation of care in residential aged care facilities: a Q methodology study” by Ludlow, Churruca, Mumford, Ellis, and Braithwaite (2020), delves into the intricate decision-making processes of care staff in Australian residential aged care facilities (RACFs) regarding how they prioritize the extensive range of care activities provided to residents. The study is grounded in the critical issue of ‘unfinished care,’ a broad concept encompassing care activities that are missed, omitted, or delayed when healthcare professionals’ workloads exceed available resources. Such occurrences, often resulting from ‘implicit rationing,’ can lead to adverse patient outcomes, including medication errors, infections, falls, and reduced quality of care and patient satisfaction. While most research on this topic has historically focused on acute care settings, this study highlights the unique susceptibility of RACFs to unfinished care due to factors like aging populations, staffing challenges, and the complex needs of residents with frailty, dementia, and multi-morbidity. Understanding prioritisation—the internal cognitive process that precedes rationing and missed care—is crucial, especially considering the limited existing research specifically on prioritisation in RACFs and the lack of perspectives from non-clinical staff. This study addresses two key research questions: “What are staff members priorities regarding the care they provide to residents?” and “How do staff members prioritise care?”.
Methodology: The researchers employed a multi-site Q methodology study, a robust approach designed to investigate subjectivity by integrating qualitative and quantitative data. The study involved 31 staff members from five Australian RACFs, purposively sampled to ensure a diverse representation of roles, including Care Assistants, Registered Nurses, Activities and Lifestyle Officers, Pastoral Carers, and Facility or Care Managers. Participants engaged in a Q sorting activity where they ranked 34 magnetic cards, each representing an aspect of resident care, on a pre-defined grid from ‘Least important’ (-4) to ‘Most important’ (+4). The cards were developed through literature review and discussions with management, featuring a statement, a graphic, and relevant examples. To gain deeper insights into their decision-making, participants simultaneously performed a think-aloud task and completed post-sorting and semi-structured interviews.
Data from the Q sorting activity were analyzed using inverted factor analysis in PQMethod V.2.35, specifically centroid factor analysis and varimax rotation, to identify clusters of participants with similar card rankings, representing distinct viewpoints or ‘shared meaning’. Factor interpretation, a largely qualitative process, involved narrativizing each factor using crib sheets, participant transcripts (analyzed with NVivo V.12), researcher field notes, and a color-coded categorization system classifying cards into clinical care, activities of daily living, respect, psychosocial care, and independence and choice.
Key Findings: The analysis revealed a four-factor solution, explaining 62% of the study variance and representing 22 participants (71%). These four distinct viewpoints on care prioritisation were:
- Prioritisation of clinical care: ensuring residents’ health and safety. This viewpoint, accounting for 23% of study variance and comprising 10 participants (including all Registered Nurses and Managers in the solution), placed the highest importance on clinical aspects such as ‘Monitoring/Safety’ (+4), ‘Medication management’ (+4), and ‘Medical condition management’ (+3). Participants often linked prioritisation to safety and the prevention of harm, as well as ensuring physical and mental health. For example, Participant 2 (Manager) stated that the top priority was “keeping the residents safe from injury or medical harm”. Despite acknowledging the importance of independence, all independence-related items (except those tied to medical care) were ranked as low priorities, with ‘Seating choice’ (-4) and ‘Choice about room environment’ (-4) being the lowest due to concerns about safety, dementia, and practical issues like mobility aids. ‘Conversations’ (-2) were also a low priority due to perceived time constraints.
- Prioritisation of activities of daily living: fulfilling role responsibilities. Representing 13% of study variance and exclusively comprising four Care Assistants, this viewpoint prioritized residents’ daily needs, such as ‘Oral care’ (+4**), ‘Assistance with meals’ (+4*), ‘Bathing and Showering’ (+3*), and ‘Toileting’ (+3). These participants were highly role-oriented, seeing these tasks as their direct responsibilities and crucial for preventing medical complications. They viewed clinical care and sharing medical information as the Registered Nurse’s role, thus ranking cards like ‘Medical condition management’ (-3**) and ‘Resident information’ (-4**) lower. Similar to Viewpoint 1, ‘Conversations’ (-2) were low priority due to busy schedules, and choice-related cards were also ranked lower due to restrictions based on resident needs.
- Humanistic approach to the prioritisation of care: enhancing residents’ wellbeing in their final years. Accounting for 14% of study variance and including both Pastoral Carers and one Care Assistant, this viewpoint prioritized residents’ overall wellbeing. High-ranked cards included ‘Emotional support’ (+4*), ‘Respect’ (+4), ‘Spiritual activities’ (+3**), and ‘Conversations’ (+2). Participants emphasized making residents’ “end stage of life” meaningful, acknowledging their individual histories and promoting human connection. Despite time constraints, ‘Conversations’ were still prioritized, with Participant 22 (Care Assistant) stating they would “find time”. While clinical care, such as ‘Medical condition management’ (+3), was important for comfort and pain minimization, activities of daily living were lower priorities. Choice-related cards were among the lowest, deemed “ideal and nice to have” but “not a deal breaker”.
- Holistic approach to the prioritisation of care: consideration of the whole care experience. This viewpoint, explaining 12% of study variance and represented by four Activities and Lifestyle Officers and one Care Assistant, presented a composite view, valuing a range of care elements. It was the only viewpoint with at least one card from each of the five care categories in the top three ranks. Broad concepts like ‘Medical condition management’ (+4), ‘Independence’ (+2), and ‘Respect’ (+3) were top priorities, reflecting a broad philosophy rather than task-focused care. ‘Social Activities’ (0**) were ranked higher than in other viewpoints, reflecting the role of Lifestyle and Activities Officers, but not among the highest, as they were not considered “life or death” situations. Choice-related cards were also among the lowest, often due to considerations of cognitive impairment. ‘Attitudes towards family’ (-4*) was one of the lowest, viewed as part of the job but not a priority.
Consistent Findings and Implications: Across all four viewpoints, a consistent and significant finding was that residents having choices about their care (e.g., room environment, seating, clothes, meals) were ranked as lower priorities. Participants often explained these decisions by citing the primacy of medical care, residents’ dementia and inability to make appropriate choices, and safety concerns. Additionally, time constraints were frequently reported as a major barrier to engaging in person-centred activities like meaningful conversations with residents.
These findings have crucial implications for missed care, demonstrating that care tasks perceived as outside a staff member’s defined role are often given lower priority and are susceptible to being missed. The study underscores a tension between policy regulations mandating person-centred care and the reality that staff in RACFs tend to prioritize more task-oriented aspects of care over respecting residents’ preferences and choices. This prioritization based on role responsibilities and task-oriented care, referred to as “it’s not my job syndrome” in other acute care settings, can impede integrated care and adversely affect resident outcomes. The authors strongly recommend adapting staff training programs to incorporate more holistic and integrated approaches to care provision to enhance safety, quality of care, and prevent care from being overlooked. Such training should aim to move beyond strict divisions of labor and promote a broader understanding of care responsibilities.
Future Research and Study Considerations: The study suggests future research should further investigate the links between role-responsibilities, care prioritisation, and missed care in RACFs, and their consequences for resident outcomes. Another area for exploration is the strategies staff use to prevent lower-priority care from being missed, such as the ‘knowledge broker’ role of Care Assistants. A strength of this study is its use of Q methodology, which produces an integrated and ‘whole’ view of care prioritisation by forcing participants to make comparative judgments. It also notably included multidisciplinary staff beyond just nurses and physicians, acknowledging the diverse workforce in RACFs. Limitations include the study being conducted within facilities of a single aged care provider, which might limit generalizability, and the exclusion of other stakeholders like allied health professionals.
In conclusion, this research provides valuable insights into the complex realities of care prioritisation in residential aged care, highlighting the significant influence of occupational roles and the pervasive challenge of balancing task-oriented duties with person-centred care, ultimately impacting the quality of life for residents.
Reference: Ludlow, K., Churruca, K., Mumford, V., Ellis, L. A., & Braithwaite, J. (2020). Staff members’ prioritisation of care in residential aged care facilities: a Q methodology study. BMC Health Services Research, 20, 209. https://doi.org/10.1186/s12913-020-05127-3