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 Shar...
• Residential aged care a growth industry. Between 2007 – 2020
demand for residential aged care places predicted to increa...
RACF Profile
Escalating trend to older age admissions, higher dependencies,
growing separations via death and increasing i...
Significance of Dementia: Predictions keep increasing
• Lack of synergy between organisational imperatives and care
imperatives (Domestic vs. Sub acute, Rehab vs. Palliative ca...
Deskilling of aged care?
In this time (2002 – 2007) the number of new
nursing graduates increased 41%
• Martin & King (200...
Workforce profile: Turnover, part time & casuals
• Relatively high turnover- 25% of PCs and 20% of nurses have to be
repla...
Burnout among elderly RNs?10
10. AIHW (2008). Nursing and midwifery labour force 2005.
Average age of RACF nurses 51.7 yrs...
Employed registered nurses: work setting and sector of main
job by nursing role, Australia 200510
AIHW (2008). Nursing and...
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 le...
• Dementia generally not regarded as a
terminal condition – ‘dementia is not
often fatal in itself” (AIHW 2011).
 Difficu...
• Prognosis from diagnosis to
death has been estimated at 4.5
years (Larson et al 2004), while
for those in the most advan...
• As a terminal condition - Need
increased attention on palliative
approaches to care for people with
dementia (PWD) in RA...
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
collabo...
DKAT2 survey administered in 8 x RACFs (Tas x 2 + Vic x 2 + WA x 4).
Care (RNs, ENs, PCAs) & other staff (n = 315).
- Inte...
Staff profile Family carer profile
• 82% female
• 20% NESB
• 24% aged < 36, 18% aged
> 55
• 13% RNs, 14% ENs
• 39% have TA...
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%
(1...
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...
Knowledge of a palliative approach (PAQ)
Question
A palliative approach:
Staff %
correct
responses
Family %
correct
respon...
Staff confidence in providing palliative care
% of staff reporting they were
confident
PCAs RN/EN
Identifying and reportin...
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 ...
• Focus groups [n~40 in 8 groups of b/w 2- & 9- members]
• Care staff (nurses and personal carers) primarily currently
wor...
Interviews/focus groups canvassed a range of areas, including:
1. Participant’s understandings of dementia;
1. How they ac...
Family members repeatedly constructed
dementia as a quasi-mental condition:
• ...with mum it is more of a mental thing ......
Staff had a similar focus…
• Because it’s there [points at head] – because dementia is
mental, it’s something not physical...
• …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 th...
Into the DU: intimations of madness, not mortality…
• ... when they put him [Dad]
into that area [DU] she [Mum]
was very u...
PWD: Mentally ill, physically well?
The persistent split articulated between physical & mental health, or the
failure to r...
Staff struggles with dementia as a terminal condition
• Well, they might have heart problems, something
else. We’ve never ...
Implications of the situation
• Lack of infrastructure to support the development of evidence
based practice – stifles inn...
Wicking Centre strategies to create a 21st
Century aged care workforce
• Create a sustainable
infrastructure to support
ev...
Thankyou
http://www.utas.edu.au/wicking/
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Andrew Robinson, University of Tasmania - Developing a 21st Century Residential Aged Care Workforce

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Andrew Robinson, University of Tasmania delivered this presentation at the 2012 Clinical Training & Workforce Planning Summit.

The 2012 Clinical Training & Workforce Planning Summit discussed the future of Australia's nursing workforce, exploring ways to ensure the capacity and experience to provide high quality care for our nation's increasing healthcare needs.

For more information, please visit http://www.informa.com.au/clinicaltraining12

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Andrew Robinson, University of Tasmania - Developing a 21st Century Residential Aged Care Workforce

  1. 1. Developing a 21st Century Residential Aged Care Workforce Professor Andrew Robinson University of Tasmania
  2. 2. 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
  3. 3. • 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
  4. 4. 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?
  5. 5. Significance of Dementia: Predictions keep increasing
  6. 6. • 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
  7. 7. 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
  8. 8. 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.
  9. 9. 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
  10. 10. 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!
  11. 11. What are the key challenges with dementia?
  12. 12. • 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!
  13. 13. • 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!
  14. 14. • 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
  15. 15. • 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
  16. 16. What is the capability of aged care staff to provide evidence based dementia care?
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Findings: Staff and family carer training
  21. 21. Findings: Staff and family carer training
  22. 22. 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
  23. 23. Findings: Comparative knowledge
  24. 24. Findings: Comparative knowledge
  25. 25. Findings: Comparative knowledge
  26. 26. Findings: Comparative knowledge
  27. 27. Findings: Comparative knowledge
  28. 28. Findings: Comparative knowledge
  29. 29. Findings: Comparative knowledge
  30. 30. Findings: Comparative knowledge
  31. 31. Findings: Comparative knowledge
  32. 32. Comparison of RACF staff & family carer knowledge
  33. 33. The impact of education on staff knowledge
  34. 34. 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?
  35. 35. 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%
  36. 36. 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%
  37. 37. Staff confidence in palliative care – by role
  38. 38. Given this knowledge base how do staff and family members understand dementia?
  39. 39. • 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)
  40. 40. • 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)
  41. 41. 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
  42. 42. 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?
  43. 43. 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]
  44. 44. • …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:
  45. 45. 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]
  46. 46. 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]
  47. 47. 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]
  48. 48. 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
  49. 49. 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.
  50. 50. Thankyou http://www.utas.edu.au/wicking/
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