The Systemic Lottery - A Field Observational Study on the Detection and Management of Acute Events in Care Homes

Care home residents represent some of the frailest and most vulnerable members of society due to impaired physical and cognitive functions. In acute situations specifically, residents often rely heavily on others to speak and act on their behalf. This places significant demands on organizational preparedness within care homes and across sectors. However, the contextual and structural processes in these situations are underexplored, potentially overlooking important contextual and clinical processes to support person-centered care in acute situations. We sought to obtain a comprehensive understanding of the circumstances surrounding acute events among residents.

A qualitative study was performed with a phenomenological and hermeneutic approach. Field observations (180 h) were conducted in four care homes in one large Danish urban municipality between October 2024 and February 2025. Purposive sampling included care homes of different sizes and districts, and acute events were included based on a predefined definition. Data analysis was inspired by Paul Ricoeur's interpretation theory.

This study is registered with the Danish Data Protection Agency (24/30952).

Based on 38 acute events, we identified three themes: (1) Care home staff have a crucial but challenged role, (2) Organizational structures in care homes shape the response, and (3) Care home residents rely on mutually dependent systems. Detection and management of acute events were strongly shaped by contextual factors, including staffing, resources, and intersectoral collaboration.

Detection and management of acute events among residents are a systemic lottery, as resident care depends more on circumstances than personal needs and preferences. This misalignment produces a structural vulnerability that puts residents at risk of compromised autonomy and integrity in acute situations and undermines visions of person-centered care.