What are power dynamics?
Power dynamics determine how people interact, whose voices are listened to and who has a say in making decisions. Power dynamics result from individual and systemic level factors. [1] They can have a big influence on the experience of both giving and receiving care.
The new rights-based Aged Care Act centres the older person as the person with the most power in making decisions about their care. [2] This shifts the model of aged care service provision from ‘doing for’ to ‘doing with’, to uphold older people’s human rights.
How are power dynamics barriers to rights-based care?
Power dynamics are present in all social and structural relationships. At the societal level, ageism is a pervasive form of bias and discrimination towards older people. [3] The digitisation of information in all forms also continues to exclude older people across society broadly, limiting their ability to access information and to participate. [4]
Structural factors can contribute to power dynamics and create barriers to providing rights-based care. These include:
- Difficulty in navigating the aged care system or lack of affordable care options [5, 6]
- Long wait times for home care packages and delays in residential placements, especially for some groups such as culturally and linguistically diverse (CALD) populations and older people living in rural areas [7]
- Paternalistic practices that limit autonomy and dignity of the older person, and make them feel disempowered. [8, 9]
Organisational level factors, like the power dynamics between aged care leaders, medical practitioners and care staff, and the extent to which person-centred care practices are prioritised, also have a substantial impact on the quality of care provided and empowerment of the older person receiving care. Read more about organisational policies and procedures and leadership and management strategies.
Individual level factors that influence power dynamics between older people and those who provide care (or anyone else) can include any vulnerabilities or unique needs the older person may have, their cultural background, socioeconomic circumstances, sexuality and any functional or cognitive limitations.
Bias and discrimination
Imbalances in power related to bias and discrimination can negatively impact older people needing care. Ageism in society generally leads to stereotypes and marginalisation of older people. [8, 10, 11] Because it is so commonplace, ageism can be internalised by the older person receiving care, making it difficult for they themselves to identify when their rights are being violated. [12] The use of ageist labels or language when providing care threatens dignity of the older person. [13, 14]
Biases can exist towards people with functional or cognitive limitations, creating tensions around the older person’s ability to make their own decisions. [9, 15]
Bias and discrimination are also sometimes experienced by people from different cultural, religious, sexual orientation or gender identity backgrounds in aged care settings. Read more on practice-specific considerations related to diversity and rights-based care.
Paternalistic practices
Power imbalances can be reinforced via paternalistic practices, for example, when well-meaning care staff (or family members) ‘take care of everything’, without giving the older person opportunity or space to make their own choices. This reinforces dependency and non-participation in decisions and activities. [9] Differing perspectives between older people and their family members in care needs and preferences can also create paternalistic tensions. Read more about family and carer influences.
A fear of repercussions, or a belief that voicing their views will not lead to action or change, can result in an older person’s non-participation in activities or care routines. [16] This can result from poor care practices, intimidation, or power imbalances between older people and care providers. [16, 17]
How are power dynamics enablers to rights-based care?
Empowering older people and supporting their care needs starts at the point aged care services are needed. The following can help to address systemic issues that impact the ability of older people to access the service they need, to enable autonomy and choice:
- Providing information in plain language, so it can be easily understood
- Allowing adequate time for older people and their supporters to thoroughly consider decisions regarding care
- Providing culturally responsive care options and translation support. [5, 6]
Older people and their families should have clear access to information and support to help them feel confident in voicing their questions and opinions and making decisions. For more information see education and empowerment for older people, families and communities.
Providing person-centred care
Dignity must always be linked to values of personhood and the unique identity and preferences of the older person. [13] Treating older people with dignity prevents discrimination and helps to overcome biases, power imbalances and paternalistic practices. [18] A sense of dignity, autonomy and empowerment for older people receiving care can be reinforced by actions such as:
- Respecting an older person’s request that care be provided by a worker of the same sex [13]
- Ensuring ample opportunities for social participation and interaction, to reinforce independence [19]
- Adapting methods of communication and/or use observation to help draw out older people’s preferences, so they feel seen and their needs are met. [13, 14, 20]
Supporting empowerment
There is an identified need to correct the damage of ageism, resulting from pervasive negative attitudes towards, or the ignoring of, older people. [18] Education about ageism in health, social and community care settings should be made a priority. [21]
Actions by workers that support empowerment of older people receiving aged care services include: treating people equally, having a positive attitude, a willingness to help and an understanding of the importance of free will. [16]
Care workers who encourage older people to ask for help when required, and who promote a sense of acceptance rather than shame around needs for assistance, foster a greater sense of autonomy among older people receiving care. [22]
The sense that it is safe to make complaints without fear of repercussions also supports dignity and a sense of autonomy of older people receiving care. [13] It is also essential to have effective processes in place to acknowledge past failures within the aged care system and help to repair harms. [3, 23, 24] For more information about complaint and advocacy pathways linked to rights-based care, read more about organisational considerations.
What can be done?
Help older people to feel informed, acknowledged and empowered when navigating care options
Policy makers:
- Ensure access to, and user-friendly information available about, a diverse range of aged care services that meet the needs of older people with unique cultural or lifestyle needs.
Organisations:
- Use simple language to provide clear, succinct information about care options and packages available.
- Support the inclusion of services and practices that meet the needs of older people with unique cultural or lifestyle needs.
Aged care workers:
- Allow time for older people and their supporters to explore options, ask questions and make decisions regarding their care.
- Make sure options for care are understood, using different methods to communicate information and to ensure older person is central to decision-making.
The evidence:
- Limited digital literacy and access and language barriers can limit access to services for older people from CALD backgrounds and other vulnerable population groups. [5]
- Consumer-directed care is meant to enable autonomy and choice, but in practice many older people have difficulty understanding the care options available to them and accessing the services they need. [5]
- Lack of information and time constraints are identified as challenges in fully involving service users in their own care decisions. [14]
- Providing human-rights based approaches to care requires that workers are able to effectively communicate the benefits and risks of all proposed and alternative care options. [25]
Support the empowerment of older people
Policy makers:
- Acknowledge the existence of pervasive ageism in society.
- Support education, training or other resources to combat ageism in society broadly.
Organisations:
- Provide top-down visibility of, and support for, processes that enable person-centred care.
Aged care workers:
- Use positive, supportive language that encourages older people to make their own decisions, participate in their care and ask for assistance when needed.
The evidence:
- Education about ageism to care providers, government and policymakers should be a priority. [21]
- The ability of person-centred care approaches to enable autonomy, dignity and participation relies on organisational recognition of the value of person-centred care to the wellbeing of the older person receiving care. [20]
- Workers can support autonomy of older people receiving care by ensuring they are involved in decision-making and by helping them to feel acceptance about any functional limitations, rather than shame. [22]
Want to learn more?
This webpage from the World Health Organisation provides information and resources about combatting ageism.
See the Australian Government’s My Aged Care resources, including:
- Navigating support for people from culturally, ethnically and linguistically diverse backgrounds
- Know your rights and how to engage an advocate or make a formal complaint