Implementing and evaluating rights-based care
Rights-based care (RBC) is a relatively new way of providing care to older people in Australia and around the world. Because it is new, there are not many studies in the peer-reviewed literature that describe tools or instruments to support implementation and evaluation of RBC. Our evidence review into operationalising rights-based care identified various tools and resources already in use.
Authors of these studies recognise these gaps and advocate for more support to study implementation and evaluation of RBC at system-, organisational- and individual person-levels.
While the grey literature offers many relevant tools and resources to implement and evaluate RBC in the Australian aged care context, there are only a few peer-reviewed tools and resources.
While some of these tools have been validated, the limited availability of validated, peer-reviewed tools reduces confidence in their reliability, validity and effectiveness.
This creates a challenge for effective evidence-based implementation, outcome measurement and comparison across aged care services.
The sections below describe the tools and frameworks supporting implementation and evaluation of RBC that are described in the peer-reviewed literature.
Embedding rights-based care in organisational culture
A human rights‑based code of conduct is a practical tool to embed person‑centred RBC across an organisation. [1] It is grounded in the PANEL principles (Participation, Accountability, Non‑discrimination and Equality, Empowerment, and Legality), which can be used to translate human rights into everyday care practice.
These principles are linked with an organisation’s values such as compassion, dignity, excellence, flourishing, justice and respect through a co‑designed principles‑by‑values matrix.
This creates a tailored and context‑specific code of conduct. It sets out how each principle should be applied in practice - for example, participation through shared decision‑making, empowerment through supporting autonomy and accountability through monitoring behaviours and outcomes. [1]
The code of conduct can be implemented through scenario‑based training that helps staff apply PANEL principles to real care situations. Before training, workers mainly focused on risk reduction and medical care.
After training, they showed a broader understanding of care and recognised the importance of empowerment, participation, dignity and respect in decision‑making, reflecting a shift away from task‑focused care toward a more holistic and relational model. [1]
Because the framework is co‑designed and aligned with an organisation’s unique values, it can be adapted to different settings while remaining grounded in human rights principles. [1]
Assessing needs and evaluating rights-based care
A book chapter on unmet needs in aged care describes 29 measurement tools that can be used to assess needs and evaluate RBC at both the individual and organisational levels. [2]
It identifies nine domains that reflect different aspects of older people’s needs and outcomes, including:
- unmet need (e.g. Camberwell Assessment of Need for the Elderly, TUNA),
- functional ability (ADLs and IADLs such as the Katz Index and Lawton Scale),
- quality of life and wellbeing (e.g. ICECAP‑O, WHOQOL‑OLD, CASP‑19),
- social participation (Australian Community Participation Questionnaire),
- health status and frailty (Tilburg Frailty Indicator),
- dementia‑specific quality of life (e.g. QUALIDEM, BASQID), and
- human rights and care quality (e.g. International Older Persons’ Human Rights Index, HCBS CAHPS, MISSCARE). [2]
At the individual level, these instruments can be used clinically to assess needs across multiple domains - physical, psychological, social, environmental and rights‑related - identify whether needs are met or unmet and inform care planning, service allocation and activity design.
Many tools also allow care staff to track changes over time, supporting monitoring of improvement or decline and the impact of specific interventions.[2]
At the organisational and system level, other instruments focus on care delivery and outcomes. For example:
- Quality‑of‑care and experience measures (such as HCBS CAHPS) identify unmet needs linked to service delivery.
- Tools like MISSCARE highlight where required care tasks are not completed.
- Broader measurement frameworks, such as WE‑THRIVE, bring together multiple domains to assess overall system performance, including workforce, organisational context and person‑centred care and outcomes. [2]
The study’s authors argue for more integrated, interdisciplinary measurement approaches combining legal, social and health domains, to strengthen how organisations assess both individual outcomes and their own performance in delivering equitable, person‑centred RBC. [2]
The Human Rights Methods in Social Work (HRMSW) scales are an evaluation tool to measure how rights‑based practice is implemented in professional settings.
The framework defines rights‑based practice as work that uses a human rights lens, applies rights‑based methods and aims toward human rights outcomes, providing a structured way to assess whether practice aligns with human rights principles. [3]
The tool consists of eight domains (scales), each capturing a different aspect of rights‑based practice:
- Participation focuses on engaging people in decisions about their care and services.
- Non‑discrimination addresses inequality and structural disadvantage.
- Strengths‑based practice emphasises recognising and building on people’s existing capacities.
- Capacity‑building focuses on developing skills and knowledge to support participation and autonomy.
- Micro/macro integration ensures that care addresses both individual needs and broader system barriers.
- Community and interdisciplinary collaboration promotes partnership across sectors and stakeholders.
- Accountability involves reflective, transparent practice.
- Finally, activism recognises that rights‑based practice is not neutral and may require challenging harmful systems and conditions. [3]
These domains provide a clear framework for assessing whether care is genuinely rights‑based.
At the individual level, they help identify whether practitioners are involving older people in decisions, addressing inequities and supporting autonomy and capability.
The scales can also be used in training and supervision to build capability in rights‑based practice and to evaluate changes in knowledge and behaviour over time. [3]
At the organisational level, the HRMSW offers a structured approach to evaluating how well services are embedding human rights principles across practice, workforce development and service design. [3]
While the tool was developed for social work, it can be applied in other practice settings, including nursing and aged care. It also encourages local adaptation to reflect different cultural, organisational and service contexts. [3]
Implementing and evaluating practice-specific considerations
The evidence also describes tools that can support practice-specific considerations including sexuality, restraint use, balancing risk, decision-making and capacity that can be used at the individual and organisational levels.
Sexuality
One article described structured tools to help services identify and address gaps in supporting intimacy. [4]
One example is the Sexuality Assessment Tool (SexAT), which enables providers to assess their environment, policies, procedures and staff capability. It is designed to identify where improvements are needed across practice, training and organisational systems, and to monitor progress over time.
This positions the tool as both a way to assess and improve how rights based practice is put into action. [5]
Similarly, digital tools such as the Mosaic app are described as supporting care teams to better understand specific populations (e.g., LGBTIQ+ residents) and to plan inclusive, person centred care. [4]
These tools focus on improving awareness, tailoring care and embedding inclusion into everyday practice.
The article also discusses tools to support decision making about intimacy. One emerging approach is advance directives on intimacy (sexual advance directives), which allow individuals to document their preferences for relationships and sexual expression in case they lose decision making capacity in the future. [4]
These tools are intended to support autonomy and continuity of relationships, while also providing legal and ethical guidance for staff and partners. However, the article notes that their implementation is still uncertain and raises ethical concerns that require further development. [4]
End of life
A key tool highlighted to support rights-based end of life care is the Physician Orders for Life Sustaining Treatment (POLST). It enables patients to formally document their preferences for end of life care in a way that is actionable within clinical settings.
Unlike traditional advance directives, the POLST translates preferences directly into medical orders, ensuring that patient wishes are followed, particularly in acute or emergency situations. [6]
The article emphasises that POLST is completed through a multidisciplinary process involving clinicians, case managers, and other professionals, making it both a decision making and communication tool across the care team.
This helps workers navigate complex decisions by grounding them in clearly documented patient preferences. [6]
Restrictive practices
There are specific tools that support clinical decision making, monitoring and reduction of physical restraint. [7]
One key tool is the standardised care process developed by the Australian Centre for Evidence Based Care (ACEBAC).
This provides an evidence based approach for residential aged care services to guide decisions about restraint use and to prioritise less restrictive strategies.
It functions as a structured practice tool, helping staff assess situations systematically and embed restraint minimisation into routine care. [7]
Another tool is the EXBELT programme, which is a multi component intervention designed to reduce restraint use in nursing homes.
The programme combines policy change, staff education and training, alternative interventions (such as hip protectors and specialised supports) and input from a consultation nurse.
It is presented as an integrated implementation tool that operationalises restraint reduction across multiple levels of care, rather than relying on a single intervention. [7]
The article also highlights the use of Quality Indicators (QIs) as a monitoring tool. Physical restraint use is measured as an indicator of care quality in several countries, tracking indicators such as frequency and type of restraint use, enabling organisations to monitor performance, benchmark practice and identify areas for improvement. [7]
At the clinical level, there are validated assessment tools used to understand behaviours associated with restraint use. These include the Neuropsychiatric Inventory (NPI), the Cohen Mansfield Agitation Inventory (CMAI) and the 4AT delirium screening tool.
These tools support workers to assess neuropsychiatric symptoms, identify underlying causes of agitation or delirium and guide decision making before restraint is considered. [7]
Finally, the article presents a ‘practical guide for clinicians’ as a structured decision support tool.
This guide outlines conducting a comprehensive assessment, prioritising alternatives, consulting with family and multidisciplinary teams, limiting restraint to exceptional circumstances and ensuring ongoing monitoring and documentation. [7]
Dignity of risk
The Colten Care Positive Risk Assessment Tool is a practical implementation tool that supports RBC by helping organisations and practitioners manage the inherent tension between promoting choice and ensuring safety. [8]
Grounded in a ‘can do’ philosophy, the tool provides a structured, defensible framework for decision‑making that aims to reduce subjectivity and support consistent care planning.
It explicitly incorporates multiple domains including medical and physical wellbeing, psychological and emotional wellbeing, social implications and ethical, spiritual or cultural factors.
This helps identify and document both the risks and benefits of an activity.
The tool prompts practitioners to document the person’s wishes, values and understanding of risk, assess their capacity and insight and weigh the potential benefits of an activity alongside the risks.
It also requires identification of control measures to minimise harm, calculation of risk levels using a structured risk calculator and documentation of consent or best‑interest decision‑making where relevant.
It emphasises active involvement of family members and representatives to ensure a balanced, collaborative approach that reflects the older person’s preferences and lived context. [8]
At the organisational level, the tool supports consistent, transparent and legally defensible decision‑making. This is done by embedding risk assessment within care planning processes.
It can be used alongside other care plans, communicated to all relevant staff and reviewed regularly as the person’s needs and circumstances change.
In practice, this approach helps shift organisational culture away from risk aversion towards positive risk‑taking.
It enables individuals to participate in meaningful activities while maintaining safety. It also provides documented evidence that decisions have been carefully considered and aligned with a rights‑based approach. [8]
Capability building
The Dignispace Massive Open Online Course (MOOC) is a structured education tool relevant to aged care workers that can support the implementation and evaluation of RBC.
The course is grounded in a human rights‑based approach operationalised through the PANEL framework - Participation, Accountability, Non‑discrimination and Equality, Empowerment and Legality.
These domains translate directly into care expectations:
- enabling people to be actively involved in decisions about their care (participation),
- ensuring systems monitor and respond to rights breaches (accountability),
- delivering equitable care without bias (non‑discrimination and equality),
- supporting autonomy and decision‑making (empowerment), and
- aligning practice with legal rights and obligations (legality). [9]
The MOOC uses a structured, progressive learning model combined with scenario‑based activities, reflective exercises and discussion forums to build practitioners’ knowledge, understanding and confidence in applying dignity in care. Evaluation findings show that this approach can strengthen aged care workers’ ability to interpret rights in practice, reflect on past care experiences and identify concrete actions to improve dignity‑focused care delivery. [9]
Artificial intelligence (AI)
The Patients’ Rights Impact Assessment (PRIA) tool is a practical implementation framework to guide the responsible and rights‑based use of AI in healthcare. [10]
The tool is a self‑assessment questionnaire that helps organisations, professionals and informal carers evaluate whether an AI application protects the health and rights of patients before it is deployed. It is grounded in a human rights‑based approach to health and is flexible across different healthcare settings. [10]
The PRIA framework is structured into three phases that cover technical performance and rights‑based outcomes.
Phase 1 (Product) focuses on the AI system itself, including its purpose, type, data quality and design, as well as its effectiveness and accuracy.
Phase 2 (Process) examines how the system is implemented in practice, including roles and responsibilities, monitoring arrangements, risk identification, mitigation measures and liability for harm.
Phase 3 (Patient) focuses on the impact on individuals, assessing how the AI application affects human rights and core patients’ rights, such as privacy, autonomy, access to healthcare and informed consent. [10]
The tool supports informed, person‑centred decision‑making by prompting explicit consideration of patient rights, preferences and potential harms. It also encourages conversations about boundaries, consent and expectations, particularly in home care settings where patients or informal carers may be selecting and using AI tools themselves. [10]
At the organisational level, the PRIA provides a structured approach to governance and accountability. It helps organisations assess risks, ensure safeguards are in place and demonstrate that decisions about AI use are aligned with legal and ethical obligations.
The PRIA can act as a ’compass‘ for decision‑making, supporting consistent, transparent and rights‑based implementation of AI technologies, particularly in complex contexts such as aged care. [10]
Evaluation frameworks, approaches and measures
Researchers suggest that human rights frameworks can be adapted to measure RBC.
The FREDA (fairness, respect, equality, dignity, autonomy) principles can be used as a practical tool to evaluate RBC. It does this by applying each principle to real incident data and checking whether each principle is upheld or violated in practice. [11]
Each principle is translated into clear, observable behaviours: for example, fairness is linked to actions like providing appropriate care, staffing and information, while violations include denying care or not following care plans.
Respect is linked to listening, supporting choices and communication, while violations include ignoring preferences or disrespectful behaviour. The same structure is applied to equality, dignity and autonomy.
Providers can then review each incident and identify whether each FREDA principle was upheld or violated. This allows a structured and consistent evaluation of RBC in real situations that can drive quality improvement. [11]
Other studies suggest the same approach, using principles from the Convention on the Rights of Persons with Disabilities [12, 13] or PANEL [14], by translating principles into concrete changes to practice.
Implications and recommendations
Implementation
Embedding RBC in practice requires coordinated supports, such as clear operational guidance to turn broad principles into clear, practical steps. This will enable aged care providers and staff deliver care that is consistent with rights-based approaches.
Legal and regulatory tools are vital to embedding RBC into laws and compliance, so that core values like dignity and autonomy become enforceable standards. Standardised definitions and policies help avoid confusion and ensure a common approach, making progress easier to track and clarifying accountability requirements.
Targeted training ensures staff have the skills and confidence to deliver RBC, fostering respect and inclusion across the workforce.
Clear implementation processes, supported by practical toolkits and change management resources, bridge the gap between theory and everyday practice. Co-designing with people with lived experience ensures initiatives fit local needs and are relevant and sustainable.
These elements create a supportive ecosystem, making RBC a reality and ensuring consistent, high-quality care that respects older people’s rights and dignity.
Evaluation
To date, there are few comprehensive evaluations of RBC, especially in aged care settings. Much of the current research examines specific aspects of RBC such as dignity, choice and participation.
While we are beginning to understand some of the potential impacts of RBC, there is limited evidence on how the overall approach performs when implemented in practice across a system.
Evaluation of RBC is often integrated into routine monitoring, documentation and feedback, rather than guided by standalone frameworks. While this approach fits well within standard practice and can give indications of the impact of some rights-based initiatives in some contexts, it can make it difficult to measure the broader impact of RBC, underscoring the need for more robust, comprehensive evaluation efforts.
Looking to the future, there are opportunities to strengthen how RBC is evaluated in aged care.
Drawing insights from disciplines and sectors such as disability services and mental health could inform the development of more comprehensive frameworks that are specifically tailored to the complexities of RBC. [3]
Using validated implementation and evaluation tools would allow systems and organisations to better demonstrate what works in RBC and ensure that care consistently upholds older people’s rights.
Want to learn more?
Explore freely available evidence-based resources to support the implementation of RBC in Australian aged care.
Read more about how to use implementation approaches to support RBC.