The RACFs participating in the USA TNH facilities were large in size (see Section1.1.2), as were those in the veterans aged care sector (see Section1.1.3) and some of the studies reviewed argued that a degree of critical mass is essential so that participating RACFs can offer diversity in residents’ care needs and services to support those needs. Those that were found to be most successful in the early USA initiatives were providing for between 250 and 300 residents (Liebig 1986: 205, citing the work of several researchers).
…a TNH will not succeed unless it can achieve a critical mass in volume of cases, clients or patients;
diversity of diagnoses; … number of students attracted to the program ….(Berdes & Lipson 1989: 19).
The literature identifies more positive than negative outcomes arising from the TNH model. However, there are challenges associated with the model and there is a need to address these in both the planning and implementation phases.
In a survey of the original eleven TNHP sites, Mezey etal (1997: 137) identified 13 barriers to TNH affiliations, which in order of frequency, are presented in Table2. This shows that the major barriers are insufficient resourcing and insufficient commitment by partners.
Table 2: Barriers to TNH affiliation (Mezey et al 1997)
A key challenge for TNHs is balancing the rights of patients with the research and publishing requirements associated with teaching and education (ACWC 2000: 2). There are also a range of ethical issues associated with undertaking research with residents of RACFs, particularly those with high level care needs and/or those not able to provide informed consent (Liebig 1986: 199).
In addition, the emphasis on consumer centred care as a key principle of aged care is not matched by equivalent attention in the research methodology literature and a reliance on traditional ‘ethical principles’ persists (McCormack 2003: 179). These are difficult to apply to many RACF residents, particularly those with dementia, and ethics procedures for the research component of TNHs thus require careful and sensitive consideration.
Research in western society is preoccupied with a rational discourse of informed consent (Johnstone,
1989). Indeed, the increasing control being exerted by ethics committees and research governance frameworks excludes approaches to consent that are not objective and rational. … The result of this is that large sections of populations are excluded from giving consent other than through ‘proxies’. Existing evidence suggests that proxy consent is unreliable as it assumes that an individual’s values
are known and understood by another person (Buchanan & Brock, 1989). Because of this dominance,
client groups such as people with dementia are largely excluded from the consent process or, worse, are sidelined as a suitable population to study directly. Much research with older people with dementia is conducted via ‘reliable informers’ on the basis that they are able to represent the person
– an unreliable position to adopt ….
…. The challenge for academic communities is to explore ways of linking in a more proactive way, the agendas of researchers with the agendas of practitioners (McCormack 2003: 184,187).
In addition, the duty of care requirements of aged care providers and their legal liabilities mean that relatively untrained students can present a risk to fulfilling those requirements without specific supervision, orientation and other measures.
The work of McCormack is useful here in its discussion of the issues and the provision of a framework of guiding principles for undertaking research in an aged care setting (McCormack 2003: 185-187). The TNHP funded Carroll Manor & the Catholic University of America School of Nursing affiliation in Ohio established a Research and Education Committee comprising nursing home staff, residents and school of nursing faculty which had the dual role of approving proposals for student placement and requests to conduct clinical research at the facility (CaseStudy2, Section 1.3.1).