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/