Residential Facilities Research Articles

Use of potentially inappropriate psychotropic medicines among older adults in 23 residential aged care facilities in Australia: a retrospective cohort study.

Psychotropic medications are frequently utilised in residential aged care facilities (RACFs). Longitudinal medication administration data can offer crucial insights into the potential inappropriate use of psychotropic medicines (PIPMs), guiding future quality improvement initiatives. This study aimed to determine the prevalence and predictors of PIPMs use and assess variation in PIPMs use by facility for residents of RACFs. We conducted a retrospective longitudinal cohort study using routinely collected electronic health data (2020-2021) relating to 3064 residents from 23 RACFs in New South Wales, Australia. The study included permanent residents aged ≥ 65 years and median length of stay was 483 days. The prevalence of PIPMs use was estimated using updated Beers criteria 2023. The extent of exposure to PIPMs was measured using two metrics i.e., number of days residents were exposed to PIPMs and the proportion of days covered by PIPMs. We used logistic regression model to determine factors associated with PIPM use. Funnel plots to visualised variation in PIPMs use across facilities. In total 40% (n = 1224) residents used at least one PIPM and 10% (n = 302) used ≥ 2. The most frequently used PIPMs categories were benzodiazepines and Z-drugs (27.4%), followed by first and second generation antipsychotics (17.2%). Certain diagnoses (dementia, pain, depression, anxiety, and endocrine disorders) were associated with the increased use of PIPMs. For example, residents with dementia were 1.94 times more likely to use ≥ 2 PIPMs (OR 1.94; 95% CI 1.50-2.51). The prevalence of at least one PIPM by residents in each facility ranged from 23.3 to 57.0% across facilities. The overall median number of days residents were exposed to PIPMs were 91 days (IQR 6-320) while the median proportion of days covered by at least one PIPM was 39.3% (IQR 2.6-86.6%). Residents in aged care facilities showed a high rate of PIPMs use with substantial variation across facilities. Quality improvement initiatives which target inappropriate psychotropic medication use are necessary, particularly considering the link between psychotropic drug use and adverse events such as falls.

SHEA practice update: infection prevention and control (IPC) in residential facilities for pediatric patients and their families.

In 2011, the Society for Healthcare Epidemiology of America (SHEA) and Ronald McDonald House Charities® (RMHC®) established a formal collaboration to develop the first IPC guideline. Both organizations agreed that RMH programs staff and other organizations operating similar programs would benefit from a standardized approach. In 2023, the collaboration was re-established to revise and update the original IPC guideline. This SHEA Practice Update on "Infection Prevention and Control (IPC) in Residential Facilities for Pediatric Patients and Their Families" addresses preventing transmission of infectious agents in "home away from home" residential settings, of which the Ronald McDonald Houses (RMHs) serve as a prototype.

Community Palliative Care: What are the Best Models?

Palliative care seeks to address the physical, psychosocial and spiritual concerns of patients with a life limiting illness and their caregivers. Early referral to palliative care improves symptoms and is the standard of care. This paper evaluates the evidence for different models of community palliative care and looks at the effects of homecare, hospice programs and residential aged care facility (RACF) interventions on symptom management, home death rate and acute health service utilization. It also examines the impact of COVID-19, telehealth, integration and staffing models on the efficacy of community palliative care. Evidence suggests that community palliative care increases the rate of death at home and may improve satisfaction with care, but effect on symptoms and acute health care utilization are less certain. Enrolment in a hospice program may decrease hospitalizations and improve satisfaction. RACF staff training interventions to improve the quality of palliative care provided to residents show mixed results across all indicators. COVID-19 saw a relative increase in the demand for community palliative care, as people opted out of the hospital system. Models of community palliative care that facilitate integration, support primary health providers, and promote technological innovation are worthy of further research.

Advanced Care Plan Among Older Chinese in Residential Aged Care: A Retrospective Review.

Worldwide in the population of older people, ethnic diversity is prevalent and therefore warrants culturally sensitive advanced care planning. This study aimed to explore advanced care planning documentation related to the cultural needs of residents of Chinese ethnicity in Australian aged care facilities. A retrospective review of advanced care plan documentation was undertaken among 31 older Chinese residents with life-limiting illnesses across two residential aged care facilities in New South Wales, Australia. Data were analyzed using descriptive statistics. 90% of residents had advanced care planning documentation. The presence of the resident and their representative and medical care directives were well documented. Specific details on the provision of palliative care that considers the person's cultural needs and preferences were limited. Findings suggest the need for further research that explores an optimal way of embedding culture-specific information and the development of a culturally sensitive advanced care plan for people of Chinese ethnicity.

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review.

Care refusal behaviors by institutionalized older adults with dementia pose significant challenges for professional caregivers in residential care settings. This scoping review mapped the determinants and effects of care refusal in this population. A systematic search of five databases identified 19 studies published between 2013 and 2023. The findings indicated that personal, relational, environmental, and organizational factors influence care refusal behaviors in institutional settings. Cognitive impairment, communication difficulties, elderspeak, unfamiliar institutional environments, and task-oriented care were key determinants. Care refusal compromised health outcomes, disrupted care provision, and exacerbated neuropsychiatric symptoms in residential care facilities. Terminological inconsistencies and methodological limitations were identified as research gaps. Developing standardized terminology and person-centered strategies represents priority areas for coordinated action across policy, practice, and research to address the impact of refusal behaviors while upholding the rights of institutionalized older adults with dementia.

Residential medication management reviews: a call for improved collaboration and systems integration in aged care

Purpose Residential Medication Management Reviews (RMMR) are a key component of safe, high-quality aged care service delivery. The RMMR is an interdisciplinary approach to medication management that relies on collaboration, communication and integration of systems. Acting as an improvement opportunity, the purpose of this paper is to present findings from a regional study, aimed at assessing the impact of RMMR on falls and hospital admissions and identifies barriers to impactful research in this area. Design/methodology/approach A three-year retrospective quantitative longitudinal practice audit was conducted in a regional state-managed high-care residential facility in Queensland, Australia. Data was collected pre-RMMR and six months post-RMMR. Findings The data collected was insufficient to achieve statistical significance or demonstrate the impact of RMMR on health outcomes. Factors impeding the research included limited ability to collect the data due to the lack of integration of information systems and limited stakeholder engagement resulting in poor recruitment. This highlights the need for improvement in RMMR processes and practices, and indeed wider research collaboration in the aged care sector. Research limitations/implications Thís paper acts as a call to action to improve research and interprofessional collaboration in Australian aged care. Originality/value The aged care industry needs high-quality research to drive practice improvement and collaborative care and service delivery. This paper advocates for improvements in the aged care sector with respect to research engagement and communication pathways between service providers. Advancement in systems integration for information sharing, recruitment of participants and stakeholder engagement will support evidence-based practice and process change.

Reduction in Restraint and Critical Incidents in a Norwegian Residential Treatment Facility for Children Aged 7–13 Following the Implementation of the Neurosequential Model of Therapeutics

In child and adolescent inpatient, residential and day-treatment facilities, the use of physical restraints and the occurrence of critical incidents are a significant problem. Restraints may sometimes be necessary if a child exhibits dangerous aggressive behavior, but may also be misused or overused, and have been shown to be preventable in many cases. This study aims to investigate if the implementation of the Neurosequential Model of Therapeutics (NMT) has an effect on the annual number of physical restraint incidents in a residential treatment facility for children with complex mental health disorders. Data before and after NMT implementation were collected from the agency’s restraint records. The results showed that post-NMT implementation, there was a substantial and sustained reduction in restraint incidents, with a Cohen’s d value of 2.03, indicating a very large effect. Limiting restraint use in treating children with complex mental health disorders can foster a safer and more therapeutic environment, with potential improvements in treatment outcomes. This study demonstrated a substantial drop in restraint incidents following the implementation of the Neurosequential Model in a residential facility for children aged 7–13. This reduction is presumably pivotal for children with complex mental health disorders, making treatment less coercive and offering promise for settings in which restraint incidents are a concern.

Air Purifiers and Acute Respiratory Infections in Residential Aged Care: A Randomized Clinical Trial.

The effectiveness of in-room air purification for the reduction of acute respiratory infections (ARIs) in residential aged-care facilities (RACFs) is unknown. To investigate the effectiveness of in-room air purifiers with high-efficiency particulate air (HEPA)-14 filters in reducing the incidence of ARIs among residents of RACFs. This randomized clinical trial used a multicenter, double-blind, 2-period, 2-treatment crossover design for 6 months from April 7 to October 26, 2023, in 3 RACFs with a bed capacity of 50 to 100 in New South Wales, Australia. The purposive sampling approach included permanent residents in private rooms in the enrolled RACFs. Data collection was performed every 2 weeks and required no additional follow-up beyond the final data collection on October 31, 2023. An air purifier containing a HEPA-14 filter was placed in rooms of participants in the intervention group, and an air purifier without a HEPA-14 filter was placed in rooms of the control participants. The groups crossed over after 3 months. The primary outcome was the incidence of ARIs, assessed with logistic mixed-model regression. Among 135 participants randomized (70 to the intervention-first group and 65 to the control-first group), 78 (57.8%) were female; mean (SD) age was 85.2 (8.6) years. In the intention-to-treat analysis, the use of air purifiers with HEPA-14 filters did not reduce ARIs compared with the control (OR, 0.57; 95% CI, 0.32-1.04; P = .07). Among the 104 participants who completed the entire study, the intervention reduced ARI incidence from 35.6% (37 participants) in the control group to 24.0% (25 participants) in the intervention group (OR, 0.53; 95% CI, 0.28-1.00; P = .048). In this clinical trial investigating use of air purifiers with HEPA-14 filters for reducing ARIs, no significant between-group difference was found in the intention-to-treat analysis. However, a significant reduction in ARIs was identified among participants who completed the entire study. These findings may help inform future large-scale studies of respiratory infectious diseases. ANZCTR identification: ACTRN12623000347662.

Art and design workshops at a residential care facility – social care professionals’ experiences of co-creation and participation in designing the physical environment

BackgroundCo-creation and participation among different user groups have been highlighted as pivotal for improving residential care facilities for older persons. However, more knowledge is needed on methods aiming to overcome challenges in constructing inclusive co-creation and participation processes. In particular, there is a need for knowledge concerning how art and design workshops could contribute to co-creation and participation of social care professionals designing the physical environment in residential care facilities. Therefore, this study aimed to examine how art and design workshops can contribute to co-creation and participation in designing the physical environment with residential care facility professionals.MethodsA qualitative method was used to investigate social care professionals’ experiences. Data were collected through semi-structured group interviews and analysed with inspiration from Corbin and Strauss’s analysis method.ResultsThis study concludes that art and design workshops could serve as deliberating and developing practices. First, the art and design workshop as a deliberating practice involves conditions that create a communication arena and space supporting professionals in sharing experiences and voicing different perspectives. Second, the art and design workshop, as a developing practice, supports shared agency through dialogue focusing on designing the physical environment in residential care facilities, using photographs, materials, and fabrics.ConclusionsThis research contributes to the understanding of the relevance of art and design workshops and co-creation between artists and social care professionals in designing the physical environment in residential care facilities. The study can be valuable in identifying important mechanisms that facilitate co-creation and participation among social care professionals, as well as the development of art and design as a tool for improving environments in residential care facilities. The research focuses on how art and design workshops could influence co-creation and participation through art and design from the perspective of social care professionals.

Eating and feeding disorders in adults with intellectual developmental disorder with and without autism spectrum disorder.

The present observational cross-sectional study aimed at investigating the prevalence of feeding and eating disorders (FEEDs) in adults with intellectual disability (ID)/intellectual developmental disorder (IDD) with or without autism spectrum disorder (ASD) and specific problem behaviours (PBs). Two hundred six adults with ID/IDD consecutively attending residential and rehabilitative facilities, 59.2% of which had co-occurring ASD, were assessed for presence of FEEDs by a structured interview specifically developed for the study and Diagnostic Manual - Intellectual Disability criteria. The 4.3% of the sample fully met the diagnostic criteria for anorexia nervosa, 6.7% for bulimia nervosa (BN) and 22.8% for binge eating disorder (BED). Furthermore, at least one observable symptom of these disorders was found in higher percentages of the sample. A higher prevalence of FEEDs was found in ID/IDD plus ASD than in ID/IDD alone. PBs were also significantly higher in participants with co-occurring ASD and had a positive correlation with the number of FEED symptoms, especially for BN and BED. The study enriches previous literature and considers novel aspects such as the behavioural/observable presentation of symptoms as well as the association with ASD and PBs. These issues deserve a specific consideration within standard psychiatric assessment and future research, especially in persons with major communication and/or cognitive difficulties.

A Pilot Study to Assess the Feasibility of Real-Time Teledentistry in Residential Aged Care Facilities

Background/Objectives: Unmet oral health needs of residents in residential aged care facilities (RACFs) arise due to the unique challenges of assessing oral health statuses and maintaining oral healthcare in RACFs. This pilot study assessed the feasibility of using real-time teledentistry under the guidance of a dentist to train RACF staff to undertake an oral health assessment. Methods: An oral health assessment of residents was first conducted by RACF staff at two Queensland, Australia RACFs using the Oral Health Assessment Tool, with an intra-oral camera connected to a laptop, through videoconferencing, under the guidance of a dentist. A survey recorded the views of RACF staff on the acceptability of the teledentistry method. The quality of the images obtained through the camera was assessed by the dentist. Finally, cost-effectiveness was calculated between teledentistry and traditional face-to-face assessments. Results: Sixteen residents (mean age 79.3 ± 8.68 years) and eight staff (mean age 33.3 ± 6.16 years) participated in this study. Both RACF staff and residents found that the real-time teledentistry set-up was user-friendly, while the dentist rated the quality of the images as acceptable for diagnostic purposes. Real-time teledentistry was more cost-effective than bringing a dentist on-site, while taking the RACF residents to an off-site dental office for examination was the most expensive approach. Conclusions: Real-time teledentistry is feasible and cost-effective, and it is an acceptable alternative to a face-to-face clinical exam for oral health assessment in RACFs. This approach could be used in RACFs where wireless internet connectivity is available.

Sequenced co-design with stakeholder communities to support the development of spaces for mental health recovery and healing

This research reports on a sequenced co-design process to engage lived experience consumers, carers, healthcare professionals, sector advocates and government representatives in co-designing spatial and experiential inputs to a residential eating disorders facility. The stakeholder community was enabled to co-design a model of care and, building on this, shape the functional brief for the design of health spaces. The stakeholder community input provided architects and designers with a more expansive understanding of user needs regarding specific architectural qualities including psychological safety, flexibility, social connection, and sensory experiences. Our approach yields insights across three interlinked areas: capacity building in the stakeholder community to develop the design language to contribute to design discussions; co-design processes to question pre-existing design assumptions; and subsequently, the development of a more nuanced brief for health spaces. The research supports designers, architects, health organizations and health planners to meaningfully engage with future users of complex healthcare environments.

Organisational and Ethical Challenges While Caring for Older People During the COVID-19 Pandemic in Sweden: AFocus Group Study.

During the COVID-19 pandemic, older people in Sweden's residential care facilities and home care services experienced high mortality rates. Prior to the pandemic, the care of older people in Sweden was challenged by organisational and regulatory changes, an ageing population and insufficient increases in staff numbers. These issues led to high staff turnover, increased workloads, stress, burnout and a perceived inability to provide satisfactory care. The pandemic brought about increased job strain, stress, anxiety, depression and post-traumatic stress disorder among the staff who cared for older people. The aim of this study was therefore to focus on assistant nurses and care aides' experiences of their work environments when caring for older people during the pandemic in Sweden. The data were collected through four focus groups interviews and analysed using qualitative content analysis. The results showed that the care staff had to navigate organisational and ethical challenges in poor and unsafe work environments. They lacked supportive leadership in their respective organisations, were neither valued, seen nor heard and were treated as 'plain doers'. During the pandemic, they were unable to protect or communicate easily with the older people in their care, which had harsh consequences. According to the participants, the pandemic left them, their working conditions and this part of the care system in a worse situation than before the pandemic. The pandemic thus revealed more unsustainable and unethical working conditions for the staff than before it, including the vulnerability of the older people in their care. The findings highlights the need of policies that ensure adequate training and instruction on medical issues, for managers responsible for overseeing the care of older people. There are also a need of provision of sufficient support for care staff and health care professionals during crises. The findings also underscore the need of feasible and efficient strategies do disseminate care information and address the psychosocial needs of older people.

Distribution of Australian dental practices in relation to residential aged care facilities: A geographic analysis.

Limited access to oral health services contributes to poor oral health in institutionalised older adults. The objective of this study was to map and analyse the distribution of residential age-care facilities (RACFs) in relation to dental practices across Australia. Age-care data were sourced from the Australian Institute of Health and Welfare. The data were categorised according to the Australian Bureau of Statistics remoteness index in each state and territory, defined by a geographic coordinate system. The structure of remoteness area data was integrated into RACF data using a geographic information system. Buffer analysis in QGIS was employed to calculate the buffer distance surrounding RACFs by identifying dental practices relative to a measuring distance. In total, Australia had 2718 RACFs and 7379 dental practices (both private 95.5% and public 4.5%). In all States, more than a third of metropolitan RACFs were within accessible reach of a private practice (ranging from 37% of RACFs in NSW to 55% in WA). However, proximity to public clinics was low, ranging from only 4% (WA) to 9% (QLD). More than one-fifth of metropolitan RACFs in NSW, QLD, WA and ACT (ranging from 20% to 24%) were not within accessible proximity of either a public or private dental clinic/practice. While more than 70% of RACFs in regional and remote Australia are reasonably close to dental practices, areas with inadequate access exist, with the highest percentage recorded in WA (6%). Ensuring an equitable distribution of dental practices relative to RACFs is crucial in bridging the service access gap in underserved areas.

The economic burden of schizophrenia spectrum disorders: clinical and functional correlates and predictors of direct costs. A retrospective longitudinal study

The economic burden of schizophrenia amounts for 1.5-3 % of healthcare expenses in developed countries, and ∼50 % derives from direct costs: 81 % of these are due to hospitalization, residential facilities and semi-residential facilities. Therefore, a better characterization of variables that influence direct costs represents a relevant issue.A total of 276 individuals with schizophrenia spectrum disorders receiving treatment from the Community Mental Health Centers of Brescia (Italy) were included in the study: for each participant socio-demographic, clinical and functional characteristics were assessed, and data related to the use of services in 2022 (then converted to costs) were collected. Regression analyses were performed to identify predictors of costs.A direct healthcare expenditure of 16477.23 (±32856.47) € per patient per year was identified. The main cost predictor was the PSP total score (p=0.005), followed by age of onset (p=0.020), and PANSS total score (p=0.033). Including PANSS sub-scales scores and PSP single items as potential predictors, the main predictor was the “socially useful activities” PSP item (p=0.002), followed by age of onset (p=0.011), and PANSS negative scale score (p=0.027).Our findings underline the need to implement rehabilitative intervention focused on the improvement of psychosocial functioning and negative symptoms, also to reduce healthcare expenses.

An Equine-Assisted Intervention Versus Non-Manualized Psychotherapy for Youth in a Residential Childcare Facility

AbstractCharacteristics of individuals with disruptive behavior disorders often include elevated externalizing behaviors such as impulsivity, defiance of authority and antagonism of social norms. Evidence shows that adolescents diagnosed with these types of disorders are particularly challenging to treat; however, therapies incorporating horses have shown some success. We examined the impact of an equine-assisted intervention compared to a non-manualized cognitive behavioral therapy in youth between 12- and 18-years old living in a residential childcare facility. Upon admittance, youth were administered three assessments: the Youth Self-Report, Adolescent Psychopathology Scale, and Basic Empathy Scale. Youth scoring in the clinical range for at least one externalizing subscale of the Youth Self-Report were assigned to equine-assisted intervention (EQI; N = 23) or non-manualized cognitive behavioral therapy (NM-CBT; N = 20) groups. Each group received a total of 7 h of treatment per week (three 2-hr group sessions and one 1-hr individual session) for 24 weeks. After 24 weeks of treatment, the same three assessments were administered a second time. There were no significant differences between the NM-CBT and EQI groups in the amount of change between assessments. A significant time effect was found for total externalizing behaviors in the Adolescent Psychopathology Scale and Youth Self-Report such that these measures were within the normal range after 24 weeks of treatment for participants in both groups.

Outdoor stays-A basic human need except for older adults in residential care facilities? Researcher-practitioner interaction crosses zones and shows the way out.

The aim of this discussion paper is to show the way to the outdoors by shedding light on conditions in the physical environment enabling outdoor stays for older adults living in residential care facilities (RCFs). The origin was that outdoor stays is a basic human need and applies to everyone. However, despite extensive research on the health-promoting values of contact with the outdoors, it seems that for older adults in RCFs this is not met because they often have difficulty getting outdoors on their own. Therefore, the access to and the conditions of outdoor environments are discussed and exemplified through two cases based on evidence-based approaches, namely the principal model of four zones of contact with the outdoors, and the Swedish version of the Sheffield Care Environment Assessment Matrix (S-SCEAM). An interdisciplinary team, including both researchers and practitioners highlights future directions by showing the way to the outdoors on a national level with six suggested points. As a reader, you will gain increased knowledge about environmental qualities that support outdoor stays as well as initiatives that are needed to achieve equal conditions related to outdoor stays in RCFs.

Investigation of a Norovirus GII.4Sydney[P16] outbreak in a care facility in Portugal, 2022

Abstract Background On the 29th of April 2022 the local Public Health unit was notified of 12 cases of acute gastroenteritis in residents of a long-term care facility (LTCF). A joint epidemiological investigation team was established and initiated an outbreak investigation to characterize the outbreak and implement infection control measures. Methods Epidemiological questionnaires were administered to staff (n = 44) and residents (n = 60). Case definition was LTCF residents or staff members with at least one of the following symptoms: diarrhoea, vomiting, nausea, between April 25th and May 14th, 2022. Stool or vomit samples were collected for 11 individuals. To assess environmental contamination fifteen food samples from previous meals and six surface samples from toilet faucets, wash tubs, and cutting boards were collected. Spatial distribution of cases within the LTCF was performed to guide infection control implementation. Results A total of 43 people met the case definition. Attack rates in residents and staff were 37% (23/63) and 42% (20/48), respectively. Of the total tested specimens, six (6/8) from residents and two (2/3) from staff were positive for the Norovirus (NoV) GII.4 Sydney [P16] variant by genotyping. Two (2/6) samples from surface swabs from the toilet faucet in the resident’s living room were also positive for NoV GII. Food samples were negative for major bacterial agents implicated in gastrointestinal outbreaks. Cases were distributed throughout the LTCF wards with no clear clustering. Four residents required hospital admission. Conclusions Results suggest person-to-person as well as environmental transmission of NoV. Identification of behavioural and spatial patterns of residents and staff and subsequent enactment of infection control strategies mitigated the outbreak. These findings reinforce the need for public health to maintain continuous technical support to LTCF on the implementation of infection control best practices. Key messages • Outbreak investigation in LTCF confirms Norovirus transmission, emphasizing the importance of infection control measures in long-term care facilities. • Study reveals Norovirus outbreak in LTCF, underscores the role of person-to-person and environmental transmission, highlighting the need for robust infection control protocols.

Abstract Strengths and difficulties Lithuania

Abstract Background Most mental health disorders begin before the age of 18, peaking at 14.5 years (Solmi, 2022) and manifest as emotional and behavioural difficulties that are more frequent in institutional social care (ISC): former foster care recipients have higher rates of depression and PTSD than the general population (Pecora, 2009). The rate of children living in residential care facilities in Europe and Central Asia is double the global average (UNICEF, 2024). This study aims to assess and compare the mental health of children in ISC centers and regular high schools. Methods A cross-sectional study was conducted in ISC centres and high schools in 2022-2023. The sample size consisted of children aged 11-17 living in ISC (n = 49) or in families (n = 193). Online anonymous survey was applied to assess the prevalence of endured violence, substance use and measure mental health outcomes using the Strengths and Difficulties Questionnaire (SDQ-25). Results A total of 242 respondents (age mean 14.6, SD = 2.12) in ISC and families showed similar poor mental health rates (42% and 44%, respectively). Prosocial behaviour problems were exhibited more by boys (p < 0.05), whereas emotional symptoms were more common in families (p < 0.001): 90% normal SDQ-25 scores in ISC vs 60% in families. Enduring psychological (38% vs 60.2%) violence was more prevalent among children in families (p < 0.05); smoking - in ISC, alcohol use - in families (p < 0.05). In both groups enduring physical violence was associated with smoking and alcohol use (p < 0.05), and overall poor SDQ-25 results strongly correlated (p < 0.001, r = 0.815, r = 0.610, respectively) with hyperactivity. Conclusions A significant part of study participants reported poor mental health outcomes with most problems in relationships with peers. Mental health risk factors such as violence or substance abuse are associated with poor emotional wellbeing while being more common among children living with families. Key messages • Children living in ISC and in families demonstrate similar level of mental health problems. • Varying prevalence of substance abuse among children living in different settings highlights the importance of environmental factors when addressing the issue.

Balancing power struggles: Understanding the dynamics between standards set by the government, adolescents, and staff at a therapeutic residential care facility

ABSTRACT During four days of observation at a therapeutic residential care (TRC) facility for adolescents with complex behavioral issues, we encountered a growing trend in the Norwegian child welfare system. High demand for institutional beds, along with reduced capacity in psychiatric services and the legal system, has led to increased reliance on the Duty to Assist obligation of the TRCs, administered by the Office for Children, Youth and Family Affairs (Bufetat) in Norway. This obligation is legally binding, ensuring the provision of justifiable treatment. Our observations of staff interactions and documentation analysis of an adolescent, Peter, revealed that staff’s ability to deliver appropriate care and manage high-risk situations is constrained by governmental standards set through law and regulation. Through the theoretical lens of power and discretion, we found that the combination of forced treatment at open institutions, with a strong emphasis on user involvement, creates a power struggle. Without clear practice standards, staff are left to rely on their own competencies in managing conflicts, resulting in inconsistent and unpredictable interactions. This inconsistency increases the likelihood that Peter will resist the care and treatment being offered.