Hitting the mark

Mary Casey provides an insight into the evolution of community care.

It is twenty years since I established the Nursing Group and I am astonished at how much things have changed when it comes to community care.

I founded the nursing service in 1993, at a time when I observed there was a stigma attached to community care and it was believed that the occupation was easier than hospital work. It was also believed that those who provided the care weren't as experienced or professional as hospital staff.

This of course was not true; however, training and further education was not an ongoing requirement for community workers back then. There were no requirements or standards.

Care provision in the community was once only done by registered nurses. When it became apparent that smaller tasks could be carried out by unregistered professionals, carers and assistants in nursing were introduced. At that point there were no industry guidelines as to what training was required.

My decision to start a nursing service was to set a benchmark for high standards of care and to also eliminate any negative stigma around community care, especially when it came to training and service provision.

Education is a major development in community care. I remember the day I opened the Casey College - I was able to create something that gave my business an edge on setting standards that would become a necessity in order to have skilled professionals caring for our most vulnerable citizens in the community. I hit the mark. Education has completely changed and students are now required to experience hands-on situations like never before.

I truly believe that nurses must learn about what it is like to be elderly or disabled by facing situations that these vulnerable people face day-in and day-out - situations such as spending a day in a wheelchair or being lifted in and out of bed, or being spoon fed. This gives our students a very thorough insight into how it is on the other side, so to speak, or to spend time in someone else's shoes. At the end of our courses we provide two weeks in a facility under supervision so that our students have a great understanding about what they will face when starting their new career. It is not so daunting and gives them a much better chance to succeed.

Another major shift was when the government expanded programs and packages in the community to allow people to stay in their homes longer and also to decrease the number of trips and admissions to hospital. Such schemes are very cost-effective and work well. Hospital stays are much shorter than ever before. Once upon a time a cholecystectomy was a 7-10 day stay; patients are now out the day after surgery. This is the case for a lot of surgery these days.

This move in the system has also changed the face of nursing in that care is more acute and nurses need to be more autonomous and responsible than ever before. This means they need to be highly skilled with a sound knowledge base. The care has become much more complex and where registered nurses once provided that care, the costs were astronomical, not to mention there was a shortage of RNs across the country.

In my view, one of the problems is that while sections of community care became complex, there were still the more menial tasks such as personal care - putting a person's stockings on or cleaning their room or cooking them a meal. It became difficult to find registered nurses who were highly trained, had spent three years at university and had to balance complex care with domestic duties.

It was obvious that this was not possible. So this is when carers and AIN's became necessary. It was easier to up-skill by providing additional training for them as opposed to finding registered nurses to do AIN's work. As a result of this, the whole community care provision changed.

Today, with the National Disability Insurance Scheme, things are going to change again, with clients making their own choices and decisions as to who will provide their care and how and when it will be done.

Time will tell if this scheme is successful or if more changes need to occur or be implemented.

Another major influencing factor in high standards of community care is pay rates. There have been some changes to these in particular areas which, in my view, are going backwards. Creating lower rates and taking penalties from nurses and carers will also lower the standards. It's common sense! Don't forget the old adage, 'Pay peanuts and you get monkeys'. In other industries, and in hospitals and for some community work, nurses receive penalties if they work Saturdays, Sundays and public holidays. Are they going to work those days for the same rate as weekdays? I don't think so! Why would they miss out on spending time with their families for no extra pay?

The problem, I believe, lies in decisions being made without proper consultation with those involved at a grassroots level. Government, non-government, the private sector and, most of all, the clientele who receive care need to work together. Policymakers need to ask those people their opinions in order to develop systems that are efficient for the people receiving the care and also if they are financially viable for the economy in general. The whole system needs to be observed from a broader perspective. Otherwise, people - those who most need the care - are given a false sense of security in terms of making their own choices and decisions.

My thought is that ongoing change is essential. Systems need to be cost-effective together with the best care possible. If they aren't, it affects all of society in one way or another.

Dr Mary Casey has over 30 years' experience in health and education. She is founder and CEO of the Casey Centre. See www.caseycentre.com.au

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