Andrew Robinson, University of Tasmania - Developing a 21st Century Residential Aged Care Workforce
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Transcript of Andrew Robinson, University of Tasmania - Developing a 21st Century Residential Aged Care Workforce
Developing a 21st Century Residential
Aged Care Workforce
Professor Andrew Robinson
University of Tasmania
Acknowledgements
• Prof Fran McInerney, ACU (Melb)
• A/Professor Christine Toye, Curtin University of Technology
• Dr Sharon Andrews, Wicking Centre, UTas
• Dr Chris Stirling, University of Tasmania
• Professor Michael Ashby, Tasmanian DHHS
• Susan Leggett, Wicking Centre, University of Tasmania
• Dr Claire Eccleston, Wicking Centre, University of Tasmania
• Cath Donohue, Australian Catholic University
Funding
• Australian Government Department of Health and Ageing
• Wicking Dementia Research and Education Centre
• Curtin University
• University of Tasmania
• Residential aged care a growth industry. Between 2007 – 2020
demand for residential aged care places predicted to increase
by 40% (Allen Consulting 2002)
• 2006-07 govt expenditure on aged care 0.7% of GDP – will grow
to 1.9% by 2046-47 - higher than both education and defence
(Prod. Comm 2008).
• Changing resident profile - Upwards shift in age at admission
associated with increasing dependency and dementia - 36%
turnover of residents every 12 months( IAHW, 2010)
• At least 50% of the total RACF population consists of PWD –
closer to 80% in high care & 100% in dementia units (DUs)
(AIHW, 2010)
Background: The growing significance of aged care
RACF Profile
Escalating trend to older age admissions, higher dependencies,
growing separations via death and increasing incidence of
residents with dementia.
What is the capability of the aged care workforce to meet this
challenge?
Significance of Dementia: Predictions keep increasing
• Lack of synergy between organisational imperatives and care
imperatives (Domestic vs. Sub acute, Rehab vs. Palliative care etc).
• Longstanding problems with recruitment - declining skill base, high
turnover, part time & casualisation.
• Limited learning culture: unsupportive work environments &
professional isolation.
• Lack of capacity to facilitate or support innovation — entrenched
hierarchies & limited history of engagement with research
Contextual issues that impact on RACF workforce capacity
Deskilling of aged care?
In this time (2002 – 2007) the number of new
nursing graduates increased 41%
• Martin & King (2008). Who Cares for Older Australians? National Institute of Labour Studies
• Department of Education, Employment and Workplace Relations. Award Course Completions 2007
Workforce profile: Turnover, part time & casuals
• Relatively high turnover- 25% of PCs and 20% of nurses have to be
replaced each year
• 50% of RNs work part time & 16.6% are permanent full-time
employees6
• Increased casualisation since 2003
Martin B & King D 2008. National Institute of Labour Studies.
Burnout among elderly RNs?10
10. AIHW (2008). Nursing and midwifery labour force 2005.
Average age of RACF nurses 51.7 yrs compared to 41.8 yrs in hospitals
Employed registered nurses: work setting and sector of main
job by nursing role, Australia 200510
AIHW (2008). Nursing and midwifery labour force 2005.
Professional Isolation!
What are the key challenges with dementia?
• Latest Australian figures identify dementia as
the third leading cause of death in Australia
(AIHW 2011) & the second leading cause of
disability burden (Al Aust 2008)
• Increasingly recognized as a progressive,
global, life-limiting, condition however, large
gaps in understanding still evident
• In later stages, PWD commonly experience:
o Eating & drinking problems;
o Dysphagia;
o Weight loss;
o Infections;
o Reduced mobility; &
o Dyspnoea
Dementia is a terminal condition!
• Dementia generally not regarded as a
terminal condition – ‘dementia is not
often fatal in itself” (AIHW 2011).
Difficulties relating to prognostication,
illness trajectory & identification of
proximal cause of death.
Consequences include inadequate
pain and symptom management,
invasive and futile diagnostic tests &
inappropriate hospitalisations
• Dementia now linked unequivocally to
high mortality rates (Mitchell et al, 2009)
Dementia is highly complex!
• Prognosis from diagnosis to
death has been estimated at 4.5
years (Larson et al 2004), while
for those in the most advanced
stage (eg those resident in
DUs), the survival time has
been estimated at 6 - 24 months
(Mitchell et al 2009)
Dementia has an unpredictable trajectory
• As a terminal condition - Need
increased attention on palliative
approaches to care for people with
dementia (PWD) in RACFs
• A palliative approach involves
partnership between staff and family.
• Care planning impacted by
knowledge of dementia
• Knowledge a mediator in care
planning communication between
staff & families –will impact on
capacity to work together
The imperative for dementia-palliation
What is the capability of aged care staff to provide
evidence based dementia care?
Survey RACF staff and family members to ascertain their
knowledge of dementia – implications for their capacity to
collaborate in implementing a palliative approach to care
• We found no single instrument that facilitated a comparative
evaluation of families’ and formal carers’ knowledge.
• To assess knowledge we adapted the Dementia Knowledge
Assessment Tool (DKAT) used in Dementia Essentials program.
• Tool modified (DKAT2) for this project to encompass family carers
- expert panel review, piloting in 3 RACFs in Vic, WA & Tas (n=30)
- pilot data demonstrated ‘good’ reliability.
- 21 items
Method
DKAT2 survey administered in 8 x RACFs (Tas x 2 + Vic x 2 + WA x 4).
Care (RNs, ENs, PCAs) & other staff (n = 315).
- Interviewer administered
- In Tas & Vic RACFs, 70% of all care staff working in the facilities
responded. In WA RACFs, 39% of care staff responded.
Family carers of PWD resident in the same 8 RACFs (n = 163).
- Tas and Vic: 3rd party recruitment and surveys mailed to their home
address, 52% response rate
- WA: surveys mailed to their home address, 28% response rate
Method
Staff profile Family carer profile
• 82% female
• 20% NESB
• 24% aged < 36, 18% aged
> 55
• 13% RNs, 14% ENs
• 39% have TAFE
certificate
• 57% female
• 2% NESB
• 64% are aged > 55 (26% are
> 65)
• 15% spouse
• 56% daughter/son
• 46% have education beyond
year 12
Findings: Staff and family carer training
Findings: Staff and family carer training
Dementia Knowledge Assessment Tool version 2 Staff Family
Dementia occurs because of changes in the brain
98% (314)
98% (155)
Only older adults develop dementia
90% (311)
85% (153)
Brain changes causing dementia are often progressive
90% (315)
93% (156)
When a person has late stage dementia, families can
often help others to understand that person's needs 85% (313)
80% (156)
Uncharacteristic distressing behaviours may occur in
people who have dementia (e.g. aggressive behaviour in a
gentle person)
96% (315)
92% (155)
A person who has dementia can often be supported to
make choices (e.g. what clothes to wear) 85% (314)
88% (154)
Findings: Comparative knowledge % correct
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Findings: Comparative knowledge
Comparison of RACF staff & family carer knowledge
The impact of education on staff knowledge
What is the knowledge base of staff and family
members about a palliative approach to care?
and
How confident are staff to provide palliative care?
Knowledge of a palliative approach (PAQ)
Question
A palliative approach:
Staff %
correct
responses
Family %
correct
responses
…needs a referral from a doctor before it can be
implemented *
52% 23%
…needs a referral from a hospital before it can be
implemented* 40% 66%
…is another name for terminal/end of life care* 35% 28%
…is appropriate for people with dementia 64% 62%
…needs to be provided in a specialised palliative care
unit or hospice
31% 61%
…needs to be delivered by staff with specialist
qualifications in palliative care
47% 86%
Staff confidence in providing palliative care
% of staff reporting they were
confident
PCAs RN/EN
Identifying and reporting
symptoms to nurse in charge
88% (252)
Mouth care
83% (247)
Nutrition and hydration 80% (246)
Communicating with relatives
about death and dying
48% (248)
37% 79%
Communicating with residents
about death and dying
42% (251)
33% 67%
Staff confidence in palliative care – by role
Given this knowledge base how do staff and family
members understand dementia?
• Purposive sample [n=14] out of a possible 60 family member
volunteered to be interviewed
• Participants’ loved ones had been resident in a DU at one of four
RACFs in metropolitan Melbourne (2) & Hobart (2) for between 12 and
36 months
• Participants comprised a range of relationships to the PWD - spouses, siblings, & offspring
• Each participated in one audio-taped, semi-structured interview of
approx one hour’s duration
Study-participant design (family)
• Focus groups [n~40 in 8 groups of b/w 2- & 9- members]
• Care staff (nurses and personal carers) primarily currently
working in the DU at one of four RACFs in metropolitan
Melbourne (2) & Hobart (2)
• Audio-taped, mixed and workforce-specific focus group of approx
one hour’s duration
Study-participant design (staff)
Interviews/focus groups canvassed a range of areas, including:
1. Participant’s understandings of dementia;
1. How they acquired such understandings;
2. Participants’ understandings of PWDs’ care;
3. Participants’ understandings of palliative care; &
4. Participant’s thoughts on the relationship between dementia &
palliative care
This presentation focuses on findings from the first question discussed
...
Method – interview/focus group areas
Family members repeatedly constructed
dementia as a quasi-mental condition:
• ...with mum it is more of a mental thing ...
because physically she seems fine but it is
just her behaviour and that sort of thing
[FDU2]
• It’s not as though he’s a sick person ... It’s
the mind involved, it’s coming from the mind
[FDU14]
• Just a confused mind ... That is in the mind
but the body to me is [sic] two different
things. You can have dementia but you can
still walk and you can still do things [FDU5]
• Body and health is reasonable, it’s the mind
that’s haywire ... [FDU11]
What is Dementia? Mindy-body split?
Staff had a similar focus…
• Because it’s there [points at head] – because dementia is mental, it’s something not physical [EN FG5]
• Just confusion. Some people are very nice, some people are very nasty… [PCA FG5]
• Somebody who’s not capable of making maybe everyday decisions. They can’t dress themselves or they can’t remember where they are or what to do even, if something’s put in front of them, what to do with it… [RN FG8]
• …behaviour...Behaviour is a key thing…But also comes aggression a lot of the time with the dementia because we’re under routine, and things have to be done and they don’t want it done, and then that triggers. So a lot of aggression comes out as well… [PCA FG2]
• …you don’t know what [sort of] dementia that person has and you
go in there you think ‘oh he has the same dementia as the other
person, the person that was always quiet, always like that’… And
then you into the room and he goes off, you might not know what's
going to happen [PCA FG4]
• ... it’s come to the stage where she’s, basically, assaulted three
people now and it’s not just going up and slapping.. [EN FG1]
Staff constructed dementia through an aberrant
behavioural lens:
Into the DU: intimations of madness, not mortality…
• ... when they put him [Dad]
into that area [DU] she [Mum]
was very upset initially
because of all the people
wandering around, and you go
to visit dad and all these
people just sort of; it’s just like
something out of, for us, One
Flew Over the Cuckoo’s Nest,
that’s how I felt as well ... it’s
just the foreign, the mental
illness thing, the dementia and
Alzheimer’s ... [DU12]
PWD: Mentally ill, physically well?
The persistent split articulated between physical & mental health, or the
failure to recognize that dementia has global effects on the brain & therefore
the body, left the issue of dying from dementia in a confused, peripheral
basket for most relatives:
• I don’t think there’s anything else wrong with mum. She’s never been a
sickly person. It’s just the way this dementia has hit her ... we think when
we go and visit her I think, she’s going to live for years ... Because her
body’s not worn out ... She’s still got her own teeth ...[DU1]
• In my mind it’s [death is] going to be an infection, it’s going to be
pneumonia because physically, I mean as far as we know, there’s nothing
else that’s wrong with her. She has not had heart problems, she’s had
the gallstones, so you know ... [DU7]
• I just was curious how, if it’s a mental condition, like ... what happens in
the body that makes you actually die from it [dementia]? [DU3]
Staff struggles with dementia as a terminal condition
• Well, they might have heart problems, something
else. We’ve never actually had somebody that’s [died
of dementia]…
• …How can you say someone’s died because of
dementia…? What would be the cause? [PCAs FG2]
• A lot of the ones that we look after with dementia,
they’ve got other underlying problems as well … I
reckon they seem to last longer when they’ve got the
dementia, because they’ve forgotten everything else
that’s wrong with them and then it might seem like
just ‘wham bam’ it just happens. So I would say you
die of something else, with dementia [EN FG4]
• I never see dementia, dying of the dementia. I never
see that they’re dead from that [PCA FG7]
Implications of the situation
• Lack of infrastructure to support the development of evidence
based practice – stifles innovation
• Care not informed by an evidence based approach – care not
configured around a palliative approach in acknowledgement
that dementia is a terminal condition
• Major capability deficits – misunderstanding dementia and
palliation
Wicking Centre strategies to create a 21st
Century aged care workforce
• Create a sustainable
infrastructure to support
evidence based practice –
Wicking Teaching Aged Care
Facility Program
• Drive the development of
evidence based approach to
dementia care – Build a model
of dementia palliation in aged
care
• Build capability to enact
evidence based dementia
palliative practice – the
Wicking Centre Associate
Degree in Dementia Care.
Thankyou
http://www.utas.edu.au/wicking/