An explorative study on facilitating and hindering conditions of implementing degrees of freedom in nursing homes

Background: (Inter)nationally, there is a rapidly aging population and thus higher numbers of chronic conditions, such as dementia. Dementia is an increasing public health problem due to high prevalence and institutionalisation. The global ‘dementia challenge’ stimulates improving dementia care, including care in institutions, where people with dementia can live on closed-door units. However, there is evidence on the health benefits of freedom of movement. Also, new Dutch legislation states that a closed-door policy should ‘always be prevented, unless…’ One option to sustain safety in maintaining an open-door policy is degrees of freedom, in which technology is being used to only open doors for certain clients who are allowed to have more freedom of movement. However, research has shown the challenges in implementation due to, among others, shifts in delivering care.

Objective: To analyse facilitating and hindering conditions during the implementation of degrees of freedom according to the main stakeholders. This will be facilitated by examining experiences of development, implementation and usage of degrees of freedom in nursing homes.

Methods: This qualitative study was performed on four closed-door units for psychogeriatric clients in two Dutch nursing homes, which were at different stages of implementing degrees of freedom. The qualitative research methods were observations with field notes on both locations and fourteen semistructured interviews with the main stakeholders. The facilitating and hindering conditions influencing the implementation of degrees of freedom were evaluated by using the non-adoption, abandonment, scale-up, spread and sustainability framework (NASSS framework).

Results: Five themes on facilitating and hindering conditions of implementing degrees of freedom emerged from the data: 1) experiences with and ease of use of technology, 2) challenges of people with dementia and degrees of freedom, 3) safety versus freedom, 4) adaption of work processes and 5) organization, locations and their exchanges in the wider context. The derived facilitating and hindering conditions could be aligned with all domains of the NASSS framework, which were labelled as either ‘complicated’ or ‘complex’. Notable was that most respondents were not in favour of the degrees of freedom. This was often the consequence of a dilemma between safety and freedom, which could play as a hindering condition during the implementation. Environmental factors, such as water nearby the exit of the location or units located on high levels, could play a role in the willingness of staff to let clients leave the units. Furthermore, the interaction between the two studied locations was investigated: exchange in and between organizations could be a facilitating condition. Lastly, the specific technology posed as a major hindering condition: respondents were highly unfavourable about the use of wristbands on people with dementia and argue for alternatives.

Conclusion: The implementation of degrees of freedom has been shown to be complex, which could lead to non-adoption. Multiple facilitating and hindering conditions were described. While the NASSS framework showed how the degrees of freedom is labelled complicated to complex, the framework was found less suitable to apprehend the cultural, paradigm and mindset shift in the respondents. Practical implications included the importance of an integral approach, necessity of mindset shift in staff towards safety versus freedom and consequences for equality in the future of elderly care. Further research should focus on a large-scale research effort on improved technology, integral approach to facility design and internal and external stakeholder engagement