Shifting the narrative from living at risk to living with risk: validating and pilot-testing a clinical decision support tool: a mixed methods study.

ABSTRACT

BACKGROUND: When there are safety concerns, healthcare professionals (HCPs) may disregard older adults' wishes to return or remain at home. A paradigm shift is needed for HCPs to move from labelling older adults as living at risk to helping them live with risk. The Living with Risk Decision Support Tool (LwRDST) was developed to support older adults and HCPs with difficult decision-making regarding living with risk. The study objectives were to (1) validate, and (2) pilot-test the LwRDST in hospital and community settings. METHODS: The study was conducted across Canada during the pandemic. The LwRDST's content was validated with quantitative and qualitative data by (1) 71 HCPs from hospital and community settings using the Delphi method, and (2) 17 older adults and caregivers using focus groups. HCPs provided feedback on the LwRDST's content, format and instruction manual while older adults provided feedback on the LwRDST's communication step. The revised LwRDST was pilot-tested by 14 HCPs in one hospital and one community setting, and 17 older adults and caregivers described their experience of HCPs using this approach with them. Descriptive and thematic analysis were performed. RESULTS: The LwRDST underwent two iterations incorporating qualitative and quantitative data provided by HCPs, older adults and caregivers. The quantitative Delphi method data validated the content and the process of the LwRDST, while the qualitative data provided practical improvements. The pilot-testing results suggest that using the LwRDST broadens HCPs' clinical thinking, structures their decision-making, improves their communication and increases their competence and comfort with risk assessment and management. Our findings also suggest that the LwRDST improves older adults' healthcare experience by feeling heard, understood and involved. CONCLUSIONS: This revised LwRDST should help HCPs systematically identify frail older adults' risks when they remain at or return home and find acceptable ways to mitigate these risks. The LwRDST induces a paradigm shift by acknowledging that risks are inherent in everyday living and that risk-taking has positive and negative consequences. The challenges involved in integrating the LwRDST into practice, i.e., when, how and with whom to use it, will be addressed in future research.