Effects of Mindfulness-Based Elder Care (MBEC) on symptoms of depression and anxiety and spiritual well-being of institutionalized seniors with disabilities: a randomized controlled trial.

BACKGROUND: Despite the need to incorporate seniors from various settings into mindfulness-based empirical research, issues of geriatric frailties and non-compliance remain. This study aimed to evaluate the effects of a mindfulness-based elder care (MBEC) program on mental health and spiritual well-being among seniors with disabilities in long-term care residential settings. METHODS: This single-blind, randomized controlled trial (RCT) randomly assigned seventy-seven participants into an MBEC group or control group of an eight-week MBEC program. Participants were assessed every four weeks at baseline (T0), mid-intervention (T1), post-intervention (T2) and follow-up (T3) using the Geriatric Depression Scale Short Form (GDS-SF), the State-Trait Anxiety Inventory (STAI) and the Spiritual Well-Being Scale (SWBS), respectively. RESULTS: Linear mixed model (LMM) showed that MBEC participants' mental health improved significantly after completing the intervention; compared with controls, the MBEC group exhibited significantly lower anxiety (state-anxiety at T2; trait-anxiety at T2 and T3) and fewer depressive symptoms. Spiritual well-being was also significantly enhanced compared to that in the control group. CONCLUSIONS: MBEC has positive effects on both mental health and spiritual well-being outcomes among seniors with disabilities. In long-term care facilities, seniors with abilities have the potential to adhere to and engage in activities of a mindfulness-based intervention. This low risk, easily accessible, and effective 8-week program is recommended to be integrated into regular long-term care institutional routines. TRIAL REGISTRATION: This study was registered with Clinical Trial Registry (ClinicalTrials.gov - U.S. National Library of Medicine #NCT05123261. Retrospectively registered on 07/04/2021.). The CONSORT 2010 guidelines were used in this study for properly reporting how the randomized trial was conducted.

Self-identified motivators for physical activity: Perspectives of older residential care facility residents.

OBJECTIVES: To inform strategies to increase physical activity amongst Older Residential Care Facility Residents (ORCFR), this research explored self-identified motivators for, benefits of and barriers to physical activity engagement. METHODS: The research was framed within a salutogenic model of health, viewing health as a continuum shaped by one's health resources and life stressors. This exploratory qualitative research examined the physical activity experiences of seven ORCFR in Brisbane, Australia. Semi-structured interviews with open-ended questions assessed basic demographics, Physical Activity (PA) levels, perceived benefits of and barriers to PA. The resulting data underwent thematic analysis. RESULTS: After seven interviews, data saturation was reached, revealing three major themes and seven subthemes. These were positive socialisation (inclusion) with subthemes of enjoying social contact and avoiding "zombieland" (loneliness). Negative socialisation (isolation) with subthemes of avoiding conflict and feeling awkward. Maintaining independence was the benefit, with subthemes of getting around to socialise, activities of daily living and preserving health to socialise. CONCLUSION: Conventional physical activity programs emphasising medical and clinical benefits are disconnected from ORCFR motivators, as residents perceive benefits in terms of mobility and socialisation. This disconnect partially explains poor acceptability and uptake of ORCFR physical activity interventions over the last 25 years.

The association between the physical environment and the well-being of older people in residential care facilities: A multilevel analysis.

AIMS: To investigate the associations between the quality of the physical environment and the psychological and social well-being of older people living in residential care facilities. BACKGROUND: Many older people in care facilities have cognitive and physical frailties and are at risk of experiencing low levels of well-being. High-quality physical environments can support older people as frailty increases and promote their well-being. Although the importance of the physical environment for residents' well-being is recognized, more research is needed. DESIGN: A cross-sectional survey of 20 care facilities from each of which 10 residents were sampled. As the individual resident data were nested in the facilities, a multilevel analysis was conducted. METHODS: Data were collected during 2013 and 2014. The care facilities were purposely sampled to ensure a high level of variation in their physical characteristics. Residents' demographic and health data were collected via medical records and interviews. Residents' well-being and perceived quality of care were assessed via questionnaires and interviews. Environmental quality was assessed with a structured observational instrument. RESULTS: Multilevel analysis indicated that cognitive support in the physical environment was associated with residents' social well-being, after controlling for independence and perceived care quality. However, no significant association was found between the physical environment and residents' psychological well-being. CONCLUSION: Our study demonstrates the role of the physical environment for enhancing the social well-being of frail older people. Professionals and practitioners involved in the design of care facilities have a responsibility to ensure that such facilities meet high-quality specifications.

Effects of an abdominal muscle exercise program in people with intellectual disabilities residing in a residential care facility.

[Purpose] The purpose of this study was to provide basic information as reference and guidelines for the implementation of abdominal muscle exercise programs for people with intellectual disabilities residing in residential care facilities. [Subjects and Methods] The study period was 12 weeks, from July 1, 2015, to September 30, 2015. The study participants comprised of 10 people with intellectual disabilities who were residing in a residential care facility. An occupational therapist measured each subject's weight and physical fitness (muscle strength and flexibility). Collected data were encoded by using items and analyzed using SPSS ver.18.0. [Results] Weight decreased significantly, and physical fitness (muscle strength and flexibility) increased significantly. [Conclusion] To actively improve abdominal muscle strength and health management in people with intellectual disabilities residing in residential care facilities, consistent implementation of abdominal muscle exercise programs and improvements are indispensable, as these could lead to the development of systematic programs for rehabilitation physical activities.

Knowledge of staff members of residential care facilities for individuals with intellectual disability on medication administration via enteral feeding tube.

BACKGROUND: Guidelines for the safe administration of drugs through enteral feeding tube (EFT) are an important tool to minimise the risk of errors. This study aimed to investigate knowledge of these guidelines among staff of residential care facilities (RCF) for people with ID. METHOD: Knowledge was assessed using a 13-item self-administered questionnaire. Questions reflected key aspects of guidelines on medication administration via EFT. All staff members that administer medication through EFT in Belgian RCFs were invited to participate (n = 553). RESULTS: Nine out of 10 RCFs participated, and 356 questionnaires were collected. Almost all participants were women (96%), and most (82%) had a non-nursing educational background. Mean self-perceived knowledge of medication administration via EFT was 6.7 (on a 0-10 scale). On average, 5.7 (SD 1.9) out of 13 questions were answered correctly. A nursing degree and previous education on medication administration via EFT were associated with significantly higher scores. Guideline recommendations regarding rinsing of used medicine cups (90% correct answers) and preparation of hard gelatin capsules (89%) were known best. Those regarding the use of protective equipment when crushing toxic substances (4% correct answers), crushing of sustained release and enteric-coated dosage forms (6%), elevation of the patient's backrest (14%) and flushing of the EFT (15%) were known the least. CONCLUSION: This study identified a substantial lack of knowledge of guidelines for drug administration through EFT among staff of RCFs for people with ID. Our findings call for tailored educational programmes in order to increase knowledge on this subject.

Effects of a walking exercise program for obese individuals with intellectual disability staying in a residential care facility.

The purpose of this study was to confirm the critical importance of active obesity management through a fitness program, and to provide foundational data required for effective obesity management of disabled persons residing in residential carse facilities. [Subjects and Methods] The study period lasted 16 weeks, from August 1 to November 30, 2014. The study participants comprised 9 individuals and they participated in a walking exercise program. An occupational therapist assessed each participant's body weight, body composition (body mass index [BMI], body fat, and abdominal fat), basic fitness (muscle strength and flexibility), and waist circumference. Collected data were encoded by items and analyzed with SPSS ver.18.0. [Results] It was found that the body weight, body composition (BMI, body fat, and abdominal fat), and waist circumference decreased significantly, while baseline fitness (muscle strength and flexibility) improved significantly. [Conclusion] Obesity management is critically important for intellectually disabled persons residing in residential care facilities. Active care through continuous program implementation is needed. Accordingly, walking exercise programs should be offered to obese intellectually disabled persons residing in residential care facilities.

Drug administration via enteral feeding tubes in residential care facilities for individuals with intellectual disability: an observational study.

BACKGROUND: The administration of oral medication to patients with an enteral feeding tube (EFT) is challenging. Compliance to guidelines concerning medication administration via EFT has been investigated extensively in the hospital setting. However, studies in residential care facilities (RCFs) for individuals with intellectual disability (ID) are very limited. Therefore, the present study aimed to collect direct observational data on drug administration practices to residents with EFT in multiple RCFs. METHOD: This cross-sectional, observational study was conducted in six Belgian RCFs for individuals with ID. Observations of medication preparation and administration through EFT were carried out in two randomly selected units per participating RCF, on 2 days per unit during all daytime drug rounds, using a direct observation method. Afterwards, the recorded observations were compared with international guidelines on drug preparation and administration through EFT. RESULTS: In total, 862 drug preparations and 268 administrations in 48 residents with EFT were witnessed. Mixing together multiple drugs, not diluting liquid formulations with at least an equal amount of water, not shaking suspensions/emulsions before use, and not selecting the most appropriate dosage form were the most common deviations from medication preparation guideline recommendations. For medication administration, not flushing the EFT with at least 15 mL water was the most common deviation. We also observed high variability in working methods regarding medication preparation and administration via EFT, even between staff members of the same unit. CONCLUSION: This study found that current guidelines concerning medication preparation and administration through EFT are often not followed in Belgian RCFs for individuals with ID. Further research aimed at understanding why current guidelines are not followed seems warranted.

Corrigendum: Effect of the nature of subsequent environment on oxytocin and cortisol secretion in maltreated children.

[This corrects the article DOI: 10.3389/fpsyt.2015.00173.].

Investigating the epidemiology and outbreaks of scabies in Japanese households, residential care facilities, and hospitals using claims data: the Longevity Improvement & Fair Evidence (LIFE) study.

Objectives: This study aimed to characterize the epidemiology of scabies and its outbreaks in Japanese households, residential care facilities (RCFs), and hospitals using claims data. Methods: This descriptive epidemiological study was conducted using claims data from eight municipalities in Japan. Scabies cases were identified using a combination of recorded diagnoses and administered medications. The study period was from April 2015 to March 2019. Outbreaks were defined as ≥2 cases of scabies occurring within a calendar month at a single household, RCF, or hospital. Results: We identified 857 scabies cases for analysis. The annual prevalence of scabies ranged from 40 to 67 per 100,000 beneficiaries. The annual attack rate of scabies was found to be highest in RCFs (21 per 1000 RCFs), followed by hospitals (11 per 1000 hospitals) and households (0.25 per 1000 households). The annual outbreak attack rate was also highest in RCFs (4.0 per 1000 RCFs), followed by hospitals (1.6 per 1000 hospitals) and household (0.027 per household). The patterns of outbreaks varied widely among the RCFs. Conclusions: The study showcases the potential of claims data for detecting infectious disease outbreaks, which could provide valuable insight for the future management and prevention of scabies. Infection control of scabies in RCFs is crucial in aging societies.

Evaluating the Indonesia Free Pasung Movement: Understanding continuing use of restraint of the mentally ill in rural Java.

Forcible restraint and confinement of persons suffering from mental illness occurs throughout the world, including in Indonesia. Since 2010, when Gerakan Bebas Pasung (GBP) or the Indonesian Freedom from Forcible Restraint (Pasung) of Mentally Ill Persons movement was launched, national policy has been published to eradicate Pasung in Indonesia by improving the mental healthcare system. This article analyses this policy, specifically the National Mental Health Legislation (2014) and the Ministry of Health Regulation Tackling Forcible Restraint of People with Mental Illness (2017), and evaluates their current state of implementation through a local, in-depth case study. Using mental health institution mapping, two sets of semi-structured qualitative interviews with government officials and healthcare workers, and participant observation in a facility practicing Pasung, we identify the extent to which the 2017 regulation has been implemented in Winong village and discuss current efforts and persistent obstacles to eradicating Pasung. We suggest that despite reforms and the new treatment facility in our case study, the continuing use of Pasung is due to a combination of access to care issues and a widely held explanatory model of mental illness characterized by strong curative beliefs that, when disappointed, lead to a sense of threat and hopelessness.

Incidence and type of restrictive practice use in residential disability facilities in Ireland, a cross-sectional study.

Restrictive practices (RPs) are a contentious issue in health and social care services. While use may be warranted in some instances, there are risks and concerns around human rights infringements. There are limited data available on the types and incidences of RPs used in health and social care services internationally. The objective of this study is to describe the type of RPs and incidence of use in disability residential care facilities (RCFs) in Ireland. RP notifications from disability RCFs reported from November 2019 to October 2020 were extracted from the Database of Statutory Notifications from Social Care in Ireland. National frequency and incidence of use of categories and type of RPs were calculated. The number and percentage of disability RCFs reporting RP use, along with the mean annual incidence of use, were also calculated. A total of 48,877 uses of RPs were notified from 1387 disability RCFs (9487 beds) during the 12-month period. The national incidence of RPs use per 1000 beds was as follows: all categories: 5152.0, environmental: 2988.2, physical: 1403.0, other: 527.0 and chemical: 233.8. The most frequently used RPs for each category was as follows: environmental: door locks, physical: other physical, other: liberty and autonomy and chemical: anxiolytics. Most RCFs (81.7%) reported at least one RPs use. The median incidence of any RPs per 1000 beds in these RCFs was 4.75 (IQR: 2.00 to 51.66). Usage of RPs was generally low, although some RCFs reported relatively high usage. Nationally, on average, five RPs were applied per resident over 12 months; environmental contributing to more than half. These findings can be used to inform policy, measure progress in reducing RPs use and for cross-jurisdiction comparisons.

Detection of anti-SARS-CoV-2-Spike/RBD antibodies in vaccinated elderly from residential care facilities in Romania, April 2021.

Introduction: SARS-CoV-2 infection rates and related mortality in elderly from residential care facilities are high. The aim of this study was to explore the immune status after COVID-19 vaccination in people 65 years and older. Methods: The study involved volunteer participants living in residential care facilities. The level of anti-Spike/RBD antibodies was measured at 2-12 weeks after complete vaccination, using chemiluminescent microparticle immunoassay (SARS-CoV-2 IgG II Quant Abbott). Results: We have analyzed 635 serum samples collected from volunteers living in 21 Residential Care Facilities. With one exception, in which the vaccination was done with the Moderna vaccine, all volunteers received the Pfizer-Comirnaty vaccine. Individuals enrolled in the study had ages between 65-110 years (median 79 years). Of the people tested, 54.8% reported at least one comorbidity and 59.2% reported having had COVID-19 before vaccination. The presence of anti-S/RBD antibodies at a protective level was detected in 98.7% of those tested (n = 627 persons) with a wide variation of antibody levels, from 7.1 to 5,680 BAU/ml (median 1287 BAU/ml). Antibody levels appeared to be significantly correlated to previous infection (r = 0.302, p = 0.000). Conclusions: The study revealed the presence of anti-SARS CoV-2 antibodies in a significant percentage of those tested (98.7%). Of these, more than half had high antibody levels. Pre-vaccination COVID-19 was the only factor found to be associated with higher anti-S/RBD levels. The significant response in elderly people, even in those with comorbidities, supports the vaccination measure for this category, irrespective of associated disabilities or previous infection.

Factors associated with perceptions of dignity and well-being among older people living in residential care facilities in Sweden. A national cross-sectional study.

The care of older people living in residential care facilities (RCFs) should promote dignity and well-being, but research shows that these aspects are lacking in such facilities. To promote dignity and well-being, it is important to understand which associated factors to target. The aim of this study was to examine the associations between perceived dignity and well-being and factors related to the attitudes of staff, the care environment and individual issues among older people living in RCFs. A national retrospective cross-sectional study was conducted in all RCFs for older people within 290 municipalities in Sweden. All older people 65 years and older (n = 71,696) living in RCFs in 2018 were invited to respond to the survey. The response rate was 49%. The survey included the following areas: self-rated health, indoor-outdoor-mealtime environment, performance of care, attitudes of staff, safety, social activities, availability of staff and care in its entirety. Data were supplemented with additional data from two national databases regarding age, sex and diagnosed dementia. Descriptive statistics and ordinal logistic regression models were used to analyse the data. Respondents who had experienced disrespectful treatment, those who did not thrive in the indoor-outdoor-mealtime environment, those who rated their health as poor and those with dementia had higher odds of being dissatisfied with dignity and well-being. To promote dignity and well-being, there is a need to improve the prerequisites of staff regarding respectful attitudes and to improve the care environment. The person-centred practice framework can be used as a theoretical framework for improvements, as it targets the prerequisites of staff and the care environment. As dignity and well-being are central values in the care of older people worldwide, the results of this study can be generalised to other care settings for older people in countries outside of Sweden.

Effects of Tooth Brushing Training, Based on Augmented Reality Using a Smart Toothbrush, on Oral Hygiene Care among People with Intellectual Disability in Korea.

(1) Purpose: In modern society, augmented reality (AR)-based training using a smart device has emerged as a means of resolving problems with training. Thus, this feasibility study aimed to identify the effects of tooth-brushing training, based on AR using a smart toothbrush, on oral hygiene care among people with an intellectual disability in Korea. (2) Methods: Thirty people with an intellectual disability, residing in a residential care facility, were selected. Tooth-brushing training based on AR, using a smart toothbrush, was applied in the experimental group (n = 15), and training using visual material was applied in the control group (n = 15). As an assessment of oral hygiene care, the changes in tooth-brushing performance and oral hygiene were measured. (3) Results: There were significant differences in all results after training between the two groups. (4) Conclusions: Tooth-brushing training based on AR using a smart toothbrush is more effective than training using visual material on oral hygiene care among the subjects of this feasibility study. Thus, training based on AR using a smart toothbrush could be applied to people with intellectual disabilities residing in residential care facilities as an individual tool for tooth-brushing training.

Improving early detection of infection in nursing home residents in South Africa.

This paper sets out key challenges related to detection and management of infection in nursing home residents, and then explores the situation in South Africa, and use of decision support tools as a mechanism to improve this area of practice. In line with global trends, concerns have been raised about the rapidly increasing aging population in South Africa and the ability of the current healthcare system to keep pace with patient demand, particularly nursing home residents. Nursing home residents, who often exhibit atypical signs and symptoms, are at increased risk of infection and unplanned admissions, which account for 65% of all bed days, and cost the US healthcare economy more than a trillion dollars a year. Evidence suggests that the current workforce in South Africa receive limited training in this area and are largely unprepared to meet the demands of the aging population. Building the capacity and skills of the workforce in South Africa is one approach that could help to improve the early detection of infection and assist the nursing home workforce to provide more effective and timely care, particularly during the current COVID-19 pandemic. Decision support tools, such as the Early Detection of Infection Scale, can help ensure consistency and ensure more timely treatment, minimising unplanned admissions and healthcare expenditure. However, the potential benefits or indeed how easily this could be integrated in to nursing homes in South Africa is unknown. An important first step, as in other parts of the world, is therefore to explore views and opinions of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes.

Spatial Optimization of Residential Care Facility Configuration Based on the Integration of Modified Immune Algorithm and GIS: A Case Study of Jing'an District in Shanghai, China.

As the population is aging rapidly, the irrationality of residential care facility (RCF) configuration has impacted the efficiency and quality of the aged care services so significantly that the optimization of RCF configuration is urgently required. A multi-objective spatial optimization model for the RCF configuration is developed by considering the demands of three stakeholders, including the government, the elderly, and the investor. A modified immune algorithm (MIA) is implemented to find the optimal solutions, and the geographic information system (GIS) is used to extract information on spatial relationships and visually display optimization results. Jing'an District, part of Shanghai, China, is analyzed as a case study to demonstrate the advantages of this integrated approach. The configuration rationality of existing residential care facilities (RCFs) is analyzed, and a detailed recommendation for optimization is proposed. The results indicate that the number of existing RCFs is deficient; the locations of some RCFs are unreasonable, and there is a large gap between the service supply of existing RCFs and the demands of the elderly. To fully meet the care demands of the elderly, 6 new facilities containing 1193 beds are needed to be added. In comparison with the optimization results of other algorithms, MIA is superior in terms of the calculation accuracy and convergence rate. Based on the integration of MIA and GIS, the quantity, locations, and scale of RCFs can be optimized simultaneously, effectively, and comprehensively. The optimization scheme has improved the equity and efficiency of RCF configuration, increased the profits of investors, and reduced the travel costs of the elderly. The proposed method and optimization results have reference value for policy-making and planning of RCFs as well as other public service facilities.

Love, Intimacy and Sexuality in Residential Dementia Care: A Spousal Perspective.

The experiences and needs of spouses of residential care facility residents with dementia, regarding friendship, love, intimacy, and sexuality were explored. Understanding of how spouses make sense of their experiences was pursued. Semi-structured interviews were held with nine spouses of people with dementia, living in high intensive 24-hour care units within residential care facilities. The results show that friendship, love, intimacy, and sexuality were still embedded in the couples' marital lives, but all in their own way. Changing roles and a shift in purpose of the relationship recurred. Although intimacy was found to be still important in the lives of spouses, emotional, and practical residential care facility barriers were experienced by the spouses, of which the absence of communication were most important. Our findings on the experiences of spouses with regard to intimacy and sexuality can help residential care facility staff and policymakers to recognize the needs of couples and take these into account.

Colonisation with pathogenic drug-resistant bacteria and Clostridioides difficile among residents of residential care facilities in Cape Town, South Africa: a cross-sectional prevalence study.

Background: Residential care facilities (RCFs) act as reservoirs for multidrug-resistant organisms (MDRO). There are scarce data on colonisation with MDROs in Africa. We aimed to determine the prevalence of MDROs and C. difficile and risk factors for carriage amongst residents of RCFs in Cape Town, South Africa. Methods: We performed a cross-sectional surveillance study at three RCFs. Chromogenic agar was used to screen skin swabs for methicillin-resistant S. aureus (MRSA) and stool samples for extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E). Antigen testing and PCR was used to detect Clostridiodes difficile. Risk factors for colonisation were determined with logistic regression. Results: One hundred fifty-four residents were enrolled, providing 119 stool samples and 152 sets of skin swabs. Twenty-seven (22.7%) stool samples were positive for ESBL-E, and 13 (8.6%) residents had at least one skin swab positive for MRSA. Two (1.6%) stool samples tested positive for C. difficile. Poor functional status (OR 1.3 (95% CI, 1.0-1.6)) and incontinence (OR 2.9 (95% CI, 1.2-6.9)) were significant predictors for ESBL-E colonisation. MRSA colonization appeared higher in frail care areas (8/58 v 5/94, p = 0.07). Conclusions: There was a relatively high prevalence of colonisation with MDROs, particularly ESBL-E, but low C. difficile carriage, with implications for antibiotic prescribing and infection control practice.

Clinical and Ethical Challenges in Undertaking LIMPRINT in Vulnerable Populations.

Background and Study Objective: To estimate the prevalence of chronic edema (CO) and wounds within two vulnerable populations, a male high security prison in the East Midlands (United Kingdom) and residential and nursing homes in the United Kingdom and Australia. Methods and Results: Methods for screening for CO and wounds were adapted from the main LIMPRINT methodology. Prison Population: In total, 195 inmates were recruited with 22 (11%) having CO. While the majority were white Caucasian (156/83.4%) a further 20 (10.7%) were dark skinned with 11 (5.95%) from other minority populations. Comorbidities included 123 (63%) smokers, 22 (11%) alcohol dependant, 60 (31%) with mental health problems, and 35 (18%) a history of self-harm. Only three had a current wound with 30 (16%) having had a traumatic stab wound. Residential and Nursing Homes (United Kingdom and Australia): In the United Kingdom, the total population available for inclusion was 189 with only 137 (73%) recruited. Seventy-two of the 137 (52%) suffered from CO and a further 16 (23%) had a history of cellulitis. Results from the Australian residential care facilities have been published in full. In summary, of the 37 participants 20 (54%) experienced CO with 25 (68%) having comorbidities and 11 (30%) having a concurrent wound. Conclusion: Obtaining an accurate picture of the prevalence and impact of CO in vulnerable populations is extremely challenging due to issues of access and consent. Lack of reliable data for these populations will contribute to poor service provision.

Balancing between maintaining and overriding the self: Staff experiences of residents' self-determination in the palliative phases.

AIMS AND OBJECTIVES: To investigate, from the staff perspective, residents' self-determination during the palliative phase while in residential care. BACKGROUND: Residential care facilities have a high prevalence of palliative care needs and dependency. The ability of residents to make and execute decisions may be hindered by their cognitive and physical limitations. There is a need to investigate how residents' self-determination is affected during the palliative phase in residential care. METHOD: Twenty individual, semi-structured interviews with Registered Nurses, enrolled nurses and physicians working in residential care facilities were analysed with inductive qualitative content analysis. FINDINGS: The overarching main theme, Balancing between maintaining and overriding the residents' self, illuminated how strengthened self-determination affected the residents' self in a positive way, while undermined self-determination affected the residents' self in a negative way. Factors that strengthened self-determination were facilitating the residents' own decision making, acting in accordance with the residents' wishes and acting as the residents' spokesperson when necessary. Factors that undermined self-determination were residents' dependence, others setting the terms, for example, being controlled by routines, insufficient communication, for example, lacking end-of-life care planning and others crossing the boundaries of one's personal sphere. CONCLUSION: There are serious threats to residents' self-determination but also strategies to cope with these threats. Physical and cognitive frailty and other people setting the terms hinder both making and executing decisions. However, staff can strengthen residents' self-determination and assist in the presentation of residents' self by adopting a relational view of autonomy and by taking personal preconditions into account. There is a need to come to terms with the lack of end-of-life care planning and to give residents a voice in these matters. Implementing a palliative approach early in the illness trajectory could facilitate communication about end-of-life care both within the group of staff and among the residents, relatives and staff. IMPLICATIONS FOR PRACTICE: To maintain residents' self-determination and protect their self, staff need knowledge about residents' life stories and personal preconditions. This in turn requires continuity of care and spending time with residents to build relationships. Implementing an early palliative approach with a focus on factors that promote quality of life for each resident might facilitate communication and enhance decision making both in everyday life and in planning for end-of-life care.