Quality procedures and complaints: nursing homes in Portugal
| Pages | 126-143 |
| Published date | 28 March 2019 |
| DOI | https://doi.org/10.1108/JAP-09-2018-0018 |
| Date | 28 March 2019 |
| Author | Ana Paula Gil |
| Subject Matter | Health & social care,Vulnerable groups,Adult protection,Safeguarding,Sociology,Sociology of the family,Abuse |
Quality procedures and complaints:
nursing homes in Portugal
Ana Paula Gil
Abstract
Purpose –In most European countries there isa range of quality control system mechanisms, however, poor
quality and institutional violence can be found in the residential sector. Taking Portugal as an example of a
country that uses an inspection-only approach, this paper focuses on the monitoring system for controlling
the quality of care in nursing homes. The purpose of this paper is to analyse how mistreatment of olderpeople
is identified and dealt with by the national social security services. In particular it looks at what the indicators
are with which to assess poor quality care and mistreatment (how it is perceived and defined), which factors
affect mistreatment of older people and intervention outputs (i.e. what are the sanctions to prevent and
combat this).
Design/methodology/approach –An exploratory approach was based on a mixed method, using a
database of 3,685 complaints reported to the social security inspection services. To understand the context
of the complaints and the assessment of institutional violence, focus groups were carried out with inspectors
from the National Inspection Service.
Findings –The focus groups identified severe situations of poor care, mistreatment of older people and loss
of human rights and dignity. Some indicators were found in key areas of care and the factors associated with
this were based on Kamavarapu’s typology (2017): physical conditions of facilities; closed organisational
models; difficult working conditions; and perceived concerns of residents. Monitoring and inspection systems
are still based on minimum standards focusing on structural and process quality, devoting little attention to
the human rights situation of older persons and clinical issues.
Research limitations/implications –The number of participants in the focus groups waslimited in size but
the uniqueness of this exploratory method draws a dark picture of non-licensed nursing homes in Portugal.
Originality/value –An exploratory analysis was useful to identify institutional violence and discuss potential
implications, in terms of effectiveness of quality care control, which calls for special attention by policy makers
and researchers when monitoring the human rights of older persons.
Keywords Care, Older people, Safeguarding, Mistreatment, Quality of care, Legal, Nursing homes
Paper type Research paper
Introduction
Institutional violence[1] is still a central issue for long-term care policy given that a greater
number of older people will require care in institutions in the next decades, due to an increase in
life expectancy. T he population of nurs ing homes tends to be t he oldest in the older p eople
group, and is thus more vulnerable to situations of abuse and neglect (McDonald et al., 2012;
Hawes, 2003).
The extension of long-term care services and facilities for older people in Europe has led to the
emergence of different care models (Greve, 2017), as well as accreditation systems for quality
care control and inspections. These systems have been established in most European countries,
both in terms of quality assurance at a governance level (a control mechanism to ensure that all
providers respect the minimum standards defined by law) and quality assurance at the level of
the provider organisation (certified quality management systems) (Leichsenring, 2010).
“The general trend is moving away from an inspection-only approach to a quality management
approach that combines inspection with advice and self-assessment reports with an effective
Received 13 September 2018
Revised 9 December 2018
2 January 2019
Accepted 16 January 2019
This work was supported by the
Foundation for Science and
Technology (Fundação para a
Ciência e a Tecnologia) in Portugal
(Grant FRH/BPD/107722/2015).
The authors would like to thank
Isabella Paoletti for her invaluable
comments and Irina Kislaya (INSA/
DEP) in the preparation of the
database.
Ana Paula Gil is based at
CICS.NOVA –Interdisciplinary
Centre of Social Sciences/
NOVA FCSH, Lisbon, Portugal.
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VOL. 21 NO. 2 2019, pp. 126-143, © Emerald Publishing Limited, ISSN 1466-8203 DOI 10.1108/JAP-09-2018-0018
internal quality management”(European Commission –DG Employment, Social Affairs and Equal
Opportunities, 2010, p. 3). However, even where there a consolidated quality control system in
Europe has been established to ensure that all services meet at least some minimum standards,
poor quality and mistreatment can be found in long-term care services (Schluter, 2010;
Drennanet et al., 2012), which leads to questions about the effectiveness of the monitoring
system of quality care control in the residential sector.
Some proposals (Organisation for Economic Co-operation and Development (OECD), 2013;
Schulmann et al., 2016), based on Donabedian’s (1997) model for assessing quality of care, have
identified three types of factors: “structural (financing and resource allocation or environmental
factors but also legal regulations and economic conditions); process-related factors
(organisational and delivery of care among different stakeholders); outcome factors (patience
satisfaction, quality of life and changes in health status)”(Schulmann et al., 2016, p. 3). These
factors can also be found in what is defined as external control of quality care. External control is
therefore to ensure that care homes comply with mutually agreed criteria for structural, process
and outcome quality, at best expressed in terms of indicators which not only focus on the quality
of nursing care, but also aspects of quality of life, leadership, economic performance and social
accountability (Leichsenring, 2010).
However, the effectiveness of the monitoring system of quality care control in the residential
sector in prevention and combat of institutional violence has received little coverage in the
literature (Pillemer et al., 2016). Recently, ENNHRI recognised that European countries should
facilitate the ongoing monitoring of the human rights situation of older people in long-term care.
The Portuguese Ombudsman Report highlights the “importance of monitoring compliance
with legal requirements and the quality of service provided in residential structures for older
persons (private and public-private partnerships), including the exercise of the corresponding
public inspection powers (e.g. regarding deficient conditions or unlawful operating)”(Portuguese
Ombudsman –Network of National Human Rights Institutions (NNHRI), 2018, p. 3).
Taking Portugal as an example of a country that uses an inspection-only approach, this paper
focuses on the monitoring system for controlling the quality of care in nursing homes[2].
The paper starts by providing an overview of the organisation of the registration and inspection of
nursing homes in Portugal, before presenting results from an exploratory study, using mixed
methods, of a database of 3,685 complaints, between 2009 and 2016, which were reported to
the Social Security Inspection Services. To understand the context and nature of the complaints,
the study included a focus group of inspectors and professional staff. The aim was to analyse
how mistreatment of older people is identified and dealt with by the national social security
services. In particular it looks at what the indicators are with which to assess quality care and
mistreatment (how it is perceived and defined), which factors affect mistreatment of older people
and intervention outputs (i.e. what are the sanctions to prevent and combat this problem).
The next section provides an overview of key issues regarding mistreatment and how they are
linked with quality care outcomes.
Linking quality care outcomes and mis treatment of older people
Estimating prevalence of institutional violence is a complex issue for research. According to
Pillemer, there is a “lack of research in this area; no reliable prevalence studies have
been conducted of such mistreatment in nursing homes or other long-term care facilities”
(Pillemer et al., 2016, p. 195). One of the reasons is because there are no prevalence studies,
based on population samples or longitudinal studies, and without prevalence estimates
it is difficult to identify risk factors (Stahl et al., 2001; McDonald et al., 2012) and, therefore, figures
obtained can be underestimated (Lindbloom et al., 2007).
Secondary data analysis, as an exploratory method, is a methodological strategy used in some
studies (Drennanet et al., 2012; Manthorpe et al., 2011; Dixon et al., 2009) to explore and clarify
definitions in an advance study of abuse and neglect in nursing homes. Findings from regulatory
inspection reports are used as secondary data, which contain evidence of poor care
practices representing a risk of mistreatment (Hyde et al., 2014; Lafferty et al., 2015).
Five organisational factors, based on nine published reports from 2000 to 2009, affected quality
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