Relational approach to ethics and quality improvement in institutional care for people with dementia

Background: Autonomy has become a key organizing principle in the official and expert discourses of the social services focused on strengthening of clients' independence and self-sufficiency. While "caring" has been seen as a threat to the autonomy of an individual, the care dependency and need for palliative care for people with dementia living in residential institutions are growing. Methods: Participatory action research was realized in 9 homes providing services for people with dementia with the aim to improve the quality of care. Research teams from the homes were involved in assisted selfassessment which included observation, documentation analysis, workshops, interviews and interventions targeting the issues arising from practice. Ethnographic research was performed by the consultant/researcher to reflect on the experience. Results: Over the last 15 years, the needs of clients in the residential care institutions in the Czech Republic have changed significantly and the pressure on people involved in direct care is growing. I suggest that relational approach to care, enhancing personal commitment of care workers and their appreciation of sociomaterialityof caring relations, is well suited for enacting autonomy and dignity of people living and dying with dementia. The relational approach to care improvement is embedded in everyday practices and thus brings a wider scope of possibilities for providing good care than the controlling mode of improvement, measuring evidence against the national standards. Conclusions: If we are, as a collective, to build up appropriate structures and resources in dementia care, more attention must be paid to the needs of residents and care workers alike, as well as to realities of the daily practices.