Addressing the oral health needs of older residents in care homes: Using the bystander intervention model to tackle an age old problem


Using the lens of the Bystander Intervention (BI) Model, the aim of this study is to explore why care home staff in residential settings fail to intervene when they witness poor oral health of an older adult. The bystander effect is a social psychological phenomenon which predicts that people are more likely to help others under certain conditions. A number of research studies on the bystander effect were prompted by the rape and killing in 1964 of Ms Catherine Genovese in New York (Darley & Latané, 1968). Several people heard or saw this incident, but no one intervened until it was too late. In an attempt to explain why no one helped her, social psychologists have devoted over forty years to the question of why people fail to intervene in what is perceived to be an emergency.

Five-step Psychological Process Model

To account for the bystander effect, Latané and Darley (1970) proposed a five stage model. They proposed that for an intervention to occur in an emergency, the bystander needs to:

  1. Notice the event
  2. Construe the situation as an emergency
  3. Develop a feeling of personal responsibility
  4. Believe that he or she has the skills necessary to succeed, and
  5. Reach a conscious decision to help

Research studies using the Bystander Intervention (BI) Model have mainly focused on emergency situations (Fischer et al. 2006; Levine & Thompson, 2004; Latané & Darley, 1970; Darley & Latané, 1968). However, the proposed research will use the BI Model in non-emergency situations (e.g. when an older patient’s oral health needs are not addressed by staff) as opposed to emergency situations (e.g. an older person lying unconscious on the ground in a subway) which the model is more commonly associated with. Thus, we are proposing a novel way of looking at the BI Model to understand the decisions that care home staff make when they witness poor oral health in a residential setting.

Poor oral health care faced by older adults residing in care homes

International studies show that the oral health care of older people in care homes or long term facilities is poor despite national and local policies championing the cause of addressing and maintaining older adults oral health (Forsell, Sjögren & Johansson, 2009; Samson et al. 2009;  Samson et al., 2008; Arpin et al., 2008; Sweeney et al. 2007; Unlüer et al. 2007; Vanobbergen & De Visschere, 2005; Simunkovi et al. 2005; Coleman, 2002; Stubbs and Riordan, 2002; Jokstad et al., 1996). Older adults in nursing homes are often unable to address their own oral health care and therefore have to depend on nurses, nurse assistants or care assistants to do this for them. However, these staff are often overworked, poorly informed about proper oral hygiene techniques, do not see oral health as a priority and fail to take responsibility for who should be providing oral health care assistance (Wardh et al. 2000; Wardh et al. 1997; Eadie & Schou, 1992; Adams, 1996). As a consequence older adults' oral health is suffering. This study will use the Bystander Intervention (BI) Model to gain a better understanding of the decision making process of care home staff when they witness poor oral health care and in doing so will test whether the BI model is applicable to non-emergency situations.

Aims and Objectives

The aim of this pilot study is to explore why staff in care homes fail to intervene when they witness poor oral health of older patients.

The following research questions will address the five stages of the BI model:

  1. How is ‘good oral health’ defined by care staff?
  2. What is the nature of the oral health concern?
  3. What cues are used in deciding whether or not a case represents poor oral health care of an older person?
  4. What kinds of decisions are made (e.g. taking personal responsibility for intervening, taking the necessary action) when care staff ascertain that an older resident has poor oral health?
  5. What are the factors that help and/or hinder reporting an incident of poor oral health?

The main objective of the proposed project will be to:

  • Provide new knowledge for understanding how the Bystander Intervention (BI) model can be used in a non-emergency situation
  • Provide greater understanding of the decisions that care staff make when they witness poor oral health care of an older adult residing in a care home
  • Explore the attitudes and meanings of good oral health care as perceived and enacted by care staff
  • Identify ways in which the culture (i.e. the experiences, attitudes, beliefs and shared norms) of the organisation enables and impedes the delivery of good oral health care practice
  • Identify the underlying mechanisms that prevent care staff from delivering good oral health care
  • Identify models of good practice which will not only benefit care staff but also older people
  • Provide wider lessons for good practice which will ultimately enable older adults living in care homes to experience good oral health care

Research Team


This research will produce quality publishable papers for an academic audience that provide insights relevant to oral health care and understanding how the bystander intervention model can be used in non-emergency situations.

Planned educational activities (related to identifying, addressing and preventing poor oral health care) will be arranged to further the education and training of care staff for the enhancement of practice.

An end of project report will be produced highlighting the facilitators and barriers to delivering good oral health care to older people residing in care homes.