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New approach to old school

It’s the fastest growing sector in health, and opportunities abound. But to attract and retain the best and brightest into aged care, a radical rethink of our education system is urgently needed.By Andrew Robinson and Barbara Horner.

A recent letter to the Medical Journal of Australia by emeritus professor Ian Maddocks highlighted key challenges facing the aged-care sector. Maddocks raises concerns around resident assessment, medication management, palliative care, inappropriate hospital transfers, poor access to medical care and the limited support for aged care staff. He argues that finding answers to these problems is “increasingly urgent”.

In a similar vein, Ludomyr Mykyta, an eminent geriatrician, raises concerns in MJA Insight recently. Mykyta suggests that despite the fact that residential aged-care facilities (RACFs) house the “sickest and most disabled people in our society”, the aged-care system has at best only limited links to mainstream healthcare services. He likens the situation to “ships that pass in the night but don’t get close to hailing range”, and goes on to argue that a lack of access to appropriate medical and specialist care is a problem.

These commentaries follow a 2013 ABC exposé of the “Aged care crisis”. Lateline spoke with families of people living in aged-care facilities who recounted disturbing stories of abuse, neglect and poor care.

As Cate Swannell suggests in her MJA commentary following Maddocks’ letter, is aged care “broken”?

The scope of the problems raised by Mykyta and Maddocks are profound, and suggest that our efforts to address these issues over the last decade have been ineffective. The reasons for that are myriad, but basically come down to a lack of staff skills, and access to appropriate, timely medical care.

The scenario confronting Australia is repeated around the western world: how to provide care to increasingly frail aged-care residents when it is difficult to recruit and retain skilled staff? Looking after old people is not high on the career list for most health professionals, so our ability to attract qualified staff is limited. A 2013 government workforce report noted that a majority of nursing homes experience shortages of registered nurses and other health professionals. By some measures, the last decade has witnessed a de-skilling of aged care. Figures from the department of health and ageing show that between 2003 and 2012 the percentage of registered nurses in nursing homes declined from more than 20 per cent to less than 15 per cent, while the percentage of care workers increased from just over 55 per cent to nearly 70 per cent. At the same time, the need for skilled staff has gone up hugely. Ten years ago, no data was collected on the number of nursing-home residents with dementia because it wasn’t deemed an important issue; today the figure is estimated at 60-80%.

Over the past decade governments in Australia have invested millions to improve aged care, but the impact has been at best variable, and at worst ineffective. A look at many nursing home websites would make you think that admission was a lifestyle choice. In reality, around 50 per cent of residents will struggle to see out the year, as people are usually admitted when they are very frail, often with a dementing illness. As Maddocks quite rightly suggests, aged care in Australia must focus on getting much better at clinical skills for complex care like dementia and palliative care. It may be hard to capture in a brochure or a website, but we need to become smarter, better trained, more skilled.

Our team’s extensive research on how to improve care in nursing homes, led by the Wicking Dementia Research and Education Centre at the University of Tasmania, shows that what we need is not more money, necessarily, but much smarter spending. First, we need to make sure the managers and executives of our aged facilities are contemporary leaders, and organisations are more responsive to the changing clinical reality of residents. Then we need to drive innovation to make sure we equip our health professionals and care workers to provide evidence based care to increasingly frail and vulnerable older people. That won’t be easy. Apart from nursing schools, very few university curricula have any appropriate content or contact with nursing homes. Universities, which train health professionals, are also “like ships that pass in the night”, and in most cases that also applies to nursing schools which generally have at best a vicarious relationship with aged care. It seems incredible that during their training most young doctors, physiotherapists, occupational therapists, pharmacists, speech therapists – the list goes on and on – have little or no engagement with nursing homes. Is it any wonder young health professionals can’t envisage a career in aged care when they have no experience of what happens? Is Maddocks’ point regarding a lack of access to appropriate medical care in nursing homes surprising when virtually no medical students undertake placements in the sector in the context of their training?

Australia is not alone. This is evident in the complete dearth of international literature that addresses medical student placements in aged care or how these might be effectively supported.

Despite aged care’s status as the fastest growing sector of health, there is little evidence that universities see it as an appropriate area for students to develop their knowledge and skills in the key healthcare issues of the 21st century: ageing, functional decline, multiple morbidity, chronic disease and dementia. In part this reflects a situation within the tertiary sector where health professional education has failed to meaningfully engage with the challenges associated with a rapidly ageing demographic. Little wonder Health Workforce Australia reports that the aged-care sector as an under-utilised area where opportunities abound. Unlike acute care, which has a deep historical partnership with universities, the aged care sector has limited engagement at any level, which isolates it from teaching and research. Organisational arrangements that actively support staff engagement in those areas are therefore limited, meaning Maddocks’ call to address the lack of support for staff will remain unrealised.

Providing leadership training to facilitate teaching and learning to individual staff who mentor students on placement in RACFs is barely emergent. Not surprising, given most supervision occurs in hospital/primary care settings where the vast majority of student placements are situated. In turn this has profound implications for the capacity of aged-care clinical leaders to drive organisational change in ways that will support the transformation of RACFs into learning organisations linking teaching, research and practice. This is critical if we are to build capacity for evidence-based practice that will drive quality resident care in the future. Our teaching hospitals illustrate that it is this nexus which lies at the heart of health professional education and excellence in care provision. It drives the development of capacity and capability among health professionals to meet the challenges of providing evidence-based health care services.

This is the conundrum of aged care. How can it be that at a time when we have acute skill shortages and evidence of poor care, most young health professionals start their careers without any real knowledge or positive experience of the fastest growing area of health? Why do universities struggle to find placements for students when we have a vast untapped resource that can be injected into the aged-care sector to drive quality that we are simply not using? Why is there such limited knowledge of – and experience with – evidence-based practice in this sector when there is such opportunity to improve practice?

One way to do this is to create teaching aged-care facilities; organisations that would parallel the great teaching hospitals. It is a concept that thrives in Norway and has a long history in the United States. Indeed, the Commonwealth Government’s 2012 Productivity Commission report recommends Australia should create them. Teaching aged care facilities are predicated, like teaching hospitals, on developing a deep and meaningful partnership between the universities and the aged care sector where there is a sharing of resources and collaboration in driving excellence. In our extensive experience working with aged care providers in three States, we can demonstrate that this approach realises organisational growth and development, builds staff capability and provides quality, valued placements for students across multiple disciplines. They could provide a new future for aged care in Australia, the foundations of a 21st century aged-care system that address the challenges raised by Mykyta and Maddocks.

Andrew Robinson is a professor of aged-care nursing, school of health sciences, and co-director of the Wicking dementia research and education centre, University of Tasmania.

Barbara Horner is an associate professor, Ageing & Dementia, at Curtin University, research collaborator and senior partner at the dementia collaborative research centre, and a research associate at the Wicking dementia research and education centre.

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