Organisational Factors in Residential Aged Care Facilities Influencing Specialised Texture Modified Diets

The objective of this scoping review is to examine and map knowledge of nursing provisions for self-determination while providing care to clients with cognitive impairment in residential aged care facilities. Maintaining the ability to have choices and to make decisions about daily activities is important for older adults. In residential aged care facilities, nurses' can be challenged to preserve clients' self-determination in favor of ritualistic care routines and a perceived duty to care. Moreover, nurses may perceive that their professional responsibilities to protect clients requires them to guard against decisions that are considered unwise or pose a risk to clients' health or safety. Insight into how nurses negotiate choice with clients with cognitive impairment who are living in a residential care facility will provide an in-depth understanding of the role self-determination plays in clients' lives. The scoping review will consider research and narrative reports on nursing provisions for self-determination in clients with cognitive impairment who are living in a residential aged care facility. The concepts of interest are self-determination and nursing provisions. Self-determination is defined as client choice and nursing provisions are the intentional reactions to clients' expressed choices. This scoping review will aim to locate published and unpublished literature employing a three-step search strategy. Only papers published in English from 1995 onward will be included. Data extracted from included papers will outline details on the participants, context, strategy, activity, and outcomes. Extracted data will be reported in a tabular form and presented narratively to address the review objective.

Why is it so hard to organise healthcare for older people in residential aged care facilities in Australia?

REVIEW QUESTION/OBJECTIVE The objective of this review is to critically appraise and synthesize evidence on the effectiveness of professional oral health care intervention on the oral health of aged care residents with dementia. More specifically the objectives are to identify the efficacy of professional oral health care interventions on general oral health, the presence of plaque and the number of decayed or missing teeth. INCLUSION CRITERIA Types of participants This review will consider studies that include residents with a formal diagnosis of dementia currently residing in permanent care in Residential Aged Care Facilities. This review will exclude participants that have not received a formal diagnosis of dementia as well as those who are not living as a permanent admission in Residential Aged Care Facilities. Studies conducted on community dwelling individuals with a formal diagnosis of dementia will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the efficacy of professional oral health care performed by a dental hygienist. These studies involve professional oral health care performed by a dental hygienist using a toothbrush, interdental brushes, floss and hand scalers if necessary to remove plaque and food debris and in some instances hardened calculus or tartar. If there are studies involving the professional oral health care being performed by dentists or a combination of dentists and dental hygienists they will be included in the analysis. This review will exclude interventions involving staff training interventions and interventions performed by nurses/assistant nurses. TRUNCATED AT 250 WORDS

The phenomenon of an ageing population is being experienced globally, as countries struggle to change and improve residential models of care and provide services to the elderly. The role of the registered nurse (RN) is considered crucial to the clinical governance and management of care given. To date, however, no systematic review has examined the RN's experience in leadership and management. The objective of this review is to critically appraise, synthesise and present best available evidence on the experiences of RNs as clinical leaders and managers in residential aged care facilities. This review considered qualitative research papers that addressed the experiences of RNs as clinical leaders and managers in residential aged care facilities. Participants of interest were RNs, nurse leaders, nurses holding registration and or regulation under a board of nursing, nurses working in residential aged care and long-term care facilities. The diversity and use of language to describe nurses' roles and models of care for the elderly care environment were considered in the review. The search strategy sought to find both published studies and papers, limited to the English language and published between January 1997 and February 2011. An initial limited search was done in Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature databases to identify the key words contained in the title or abstract and index terms used to describe the relevant terms in the article. A second extensive search was undertaken and extended to other relevant databases using all identified keywords and index terms. The third step involved searching reference lists and bibliographies of chosen articles for additional studies. Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information package. As both reviewers were in agreement on all studies included, a third reviewer was not required. A final total of eight papers, qualitative in nature, were included in the review. The majority of papers examined the experiences of nurses' leadership styles and the management characteristics within their organisations. The qualitative papers were analysed using The Joanna Briggs Institute-Qualitative Assessment and Review Instrument.The process of meta-synthesis embodied in this programme involves the aggregation or synthesis of findings or conclusions. Five syntheses were derived with key themes related to education, professional nursing development, positive attitudes to aged care and the need for a supportive environment. Nurses that work in the aged care environment show a strong motivation to work in care and provide the best outcomes in nursing the elderly. Geriatric nursing is considered a specialised and complex area of healthcare by the nursing profession. Nurses experience a lack of professional support and collaboration from allied health and medical colleagues. There is a lack of specific education that is focused in clinical leadership and health team management. There is no current structured pathway of learning and development for nursing careers in aged care. Nurses identify with their leadership role in residential aged care, and experience paradoxical feelings of being valued by the clients and devalued by the system at the same time. Organisational barriers are strong in preventing continuing education and skills development for nurse leaders in aged care environments. Overall the themes presented in the review reported the negative experiences of nurses in residential aged care and geriatrics. Nurses will continue to be devalued if there is no professional identity and support for their roles and need to have a career pathway when making the decision to enter into aged and geriatric practice. Clinical leadership training is needed for nurses to transition through practice into specialised roles such as the RN team leader and Geriatric Nurse Practitioner (GNP). Providing a career structure and choice in the industry for the nurse to become a clinical leader or a manager of health services will improve recruitment and retention. IMPLICATION FOR RESEARCH: More research is needed to identify the skills gaps experienced by nurses in aged care and geriatric care. This research could lead to the design and implementation of a skills audit to identify candidates for specialised courses so that clinical leadership and governance in aged care are improved. More research is needed for role construction and the professional development of the GNP. Organisations can benefit from research currently being conducted on the role of the RN in aged care and geriatrics, by mapping the skills mix of candidate RNs to the key performance indicators in the role. Organisations must change their perception and value of RNs as clinical leaders in care teams.

Embedding pharmacists in residential aged care: Why it's important to integrate resident‐ and system‐level services

The purpose of this scoping review was to examine teaching strategies and activities used in nursing students' clinical placement in residential aged care facilities. Population aging necessitates that nursing curricula ensure student interest and commitment to working with older adults. While searching for suitable clinical placements that provide students with opportunities to care for older adults, nursing programs have turned to residential aged care facilities. Studies show that carefully planned placement in these environments supports students' needs and offers rich learning possibilities. This review examined intentional teaching strategies and activities used during student placement in residential aged care facilities, and considered research and textual papers on the subject. The strategies and activities included those that took place prior to, during, or after the experience. The review included qualitative and quantitative research reports as well as text and opinion papers. Only research reports and papers published in English from 1992 to August 2019 were included. The databases searched were: CINAHL (EBSCO), MEDLINE (Ovid), Academic Search Premier (EBSCO), Embase (Elsevier), ERIC (EBSCO), ProQuest Dissertations and Theses, and Google (with advanced search strategies). Two independent reviewers screened citations for inclusion while a third reviewer resolved discrepancies. A table was developed for data extraction to record data relating to the review objective. Specific data extracted included the details on research design, geographical location, year of publication, description of the teaching strategy or activity. Of the 84 research reports and papers that were eligible for full-text review, only 25 (30%) were included in the final set. Sixteen papers were research reports including a variety of qualitative, quantitative, and mixed method designs. The remaining nine were textual papers and included frameworks, descriptions, and evaluations of a teaching strategy or activity. Most research reports and papers identified more than one strategy and/or activity used concurrently. The use of care staff as student mentors and facility orientation for students were the two most common strategies and activities reported. A range of teaching approaches during clinical placements in residential aged care facilities was revealed. These approaches targeted students, staff of aged care facilities, and nursing faculty. Collaborative efforts between aged care facilities and educational institutions allowed for the pooling of resources and the delivery of teaching approaches to students and the engagement of care staff. Many of the approaches were co-designed by educational programs and residential aged care facilities. The number of approaches that used more than one teaching strategy and/or activity reflects an appreciation for the importance of student placements and the complexities of aged care facilities. A lack of longitudinal or evaluative research highlights a gap in the literature. There is a need for further work to understand and evaluate the long-term effects and benefits of teaching strategies and activities used to enhance students' clinical placements in resident aged care facilities.

Even before the COVID-19 pandemic, in many parts of the world there have been considerable, ongoing concerns about care quality provision for older people, particularly for those in residential aged care facilities. People understand that something has been fundamentally corrupted when the care of our older citizens becomes 'simply another commodity to be purchased, rather than an essential service that is their right' (Davidson, 2018: 104).

Objective To compare the historical staffing patterns and organisational characteristics of Australian residential aged care facilities (RACFs) against the new minimum staffing standards recommended by the Royal Commission into Aged Care Quality and Safety (RCACQS). Method Retrospective data analysis was used to compare the staffing levels and characteristics of 1705 RACFs (for 4 years, 2016-19) with the three new mandatory staffing requirements. De-identified datasets were provided by the RCACQS, obtained under its legal authority. Results Only 3.8% of RACFs have staffing levels at or above all three requirements. Although many (79.7%) already meet the requirement to have a registered nurse (RN) on-site for morning and afternoon shifts, few have staffing levels above requirements for total direct care per resident per day (10.4%) or care provided by an RN per resident per day (11.1%). Historical levels of on-site RNs, total direct care, and RN care vary significantly across facilities of different size, location and provider scale. Conclusion The new staffing standards, to be mandatory by 2023, prescribe minimum requirements significantly higher than existing levels, particularly in care per resident per day. Each of the three requirements will likely have a differential effect for different types of RACFs. What is known about the topic? International evidence suggests that introducing mandatory minimum staffing standards tends to increase the amount of care provided by staff in residential aged care facilities (RACFs). However, the impact of staffing standards is influenced by the stringency of the minimum threshold relative to existing staffing levels, the capacity of organisations to increase their staffing levels, and the specific way the regulation is formulated. What does this paper add? This paper explores the potential implications of the three national minimum staffing standards, to be in force by October 2023, specifying total direct care, care received by a registered nurse (RN), and an RN on-site. By examining the existing staffing levels of Australian RACFs, it identifies the extent to which facilities already meet the new standards and the characteristics of facilities with staffing levels above and below the three requirements (individually and in combination). What are the implications for practitioners? The study informs both policy and practice in relation to the likely effects of implementing the national minimum staffing standards for residential aged care in Australia. It demonstrates that the new minimum thresholds are likely to require substantial increases in staffing across the sector, both in terms of all direct care workers and RNs. It also shows that the three requirements are likely to have a differential effect for RACFs of different size, location and chain affiliation, thereby guiding policy about the future needs for Australia's aged care workforce.

COVID-19 in people resident in aged care facilities: now the main game in town?

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

Aim: To determine the prevalence of malnutrition in Queensland public acute and residential aged care facilities, and explore effects of variables associated with malnutrition in these populations.Methods: A multicentre, cross‐sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single‐day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same‐day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression.Results: A mean of 34.7 ± 4.0% and 31.4 ± 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, male (in residential aged care facilities), metropolitan location of facility and medical specialty, in particular, oncology and critical care.Conclusion: Malnutrition is significant in public acute and residential aged care facilities in Queensland. Action must be taken to increase the recognition, prevention and treatment of malnutrition especially in high‐risk groups.

Despite there being acknowledgement by the aged care industry of the presence of complex persistent pain in older people living in residential care facilities (RCFs), pain continues to be under-recognised and poorly managed. This is particularly the case for residents from culturally and linguistically diverse (CALD) groups and those living with dementia. Some initiatives in this area include the development of multiple assessment tools, advancement of pharmacological and non-pharmacological strategies, the development of best practice guidelines and increased education. However, little advancement has been made in establishing and sustaining best practice in this area of care. There is also a lack of research examining how knowledge and best practice, on a broader scale, are sustained within RCFs, through ongoing learning.Using a mixed methods approach, this research, conducted in two phases, aimed to identify what factors impact on organisational knowledge and the sustainability of evidence-based (EB) pain management practices in aged care. Phase One was conducted in an RCF that had previously implemented the Australian Pain Society’s (APS) best practice guidelines (Goucke et al., 2005) and it investigated what individual and organisational factors impact on the ability of the direct care staff (registered and enrolled nurse, allied health and care workers) to undertake EB pain management practices. Phase Two was conducted in two Registered Training Organisations (RTOs) in Queensland and it investigated, how current education practices for workers with Certificate III in Aged Care (the primary workforce), influence their ability to conduct EB pain management practices.Organisational learning theory (OLT) was utilised in this research, specifically the organisational learning theoretical framework as proposed by Argote and Miron-Spektor (2011). This framework provided the tool for analysing how factors from the external environmental context (e.g. government policy and legislation) and internal contextual factors (organisational and individual), influence the way in which knowledge about pain management practices is attained, retained and transferred (Argote & Miron-Spektor, 2011).The findings of this research indicate that, two years after implementation of EB pain management strategies, best practice was not sustained and a number of resident, staff, organisational and system factors, influenced the maintenance and utilisation of organisational knowledge. This research also found, that Certificate III care workers obtained only basic knowledge of pain identification and management practices in the course, through one hour of education, primarily provided in the palliative care module. They received limited education or mentoring in these practices and processes, once they were employed in a care worker role. Clinical Facilitators (CFs) involved in care worker training, typically had a Certificate III in care work only and had varying levels of experience and knowledge in pain management practices and processes. The teaching methods utilised in the workers’ education were didactic, with use of workbooks or a power point presentation.The results indicate there are significant individual and organisational factors that impact the sustainability of EB pain management practices in aged care. Inadequate maintenance of best practice, affects the older person’s quality of life and contributes to unnecessary suffering. Whilst many of these factors have previously been documented in the literature as impacting on pain management processes in RCFs, there appears to have been minimal advances in resolving the issues. Knowledge regarding pain identification, assessment and management, may be attained through education and the provision of guidelines. However, the utilisation, retention, and transference of this knowledge within aged care facilities, appears to decline after initial implementation. If best practice is to be sustained, managers and clinical leaders in RCFs, need to utilise a framework or model, such as provided in the organisational learning theoretical framework, to identify potential barriers and facilitators, consider what happens beyond the initial implementation phase and strategically plan how the RCF can sustain knowledge and best practice, given their current human and physical resources. The aged care industry, nursing as a professional body and the public at large, needs to pressure the government to improve staff ratios and skill mix. There also needs to be a pressure placed on the government and training providers, to improve the standard of education offered in the Certificate III/IV aged care training material. Improved education for care workers in pain management (and other clinical areas), would better equip them, for work in the current aged care environment, where care that is more complex is required for older people now being admitted to RCFs.If we do not make some considerable efforts to address the ongoing poor recognition and management of pain in RCFs, then we will continue to fail in our duty of care to one of the most vulnerable groups in our population. Older people have the right to have their pain managed appropriately.

Introduction: Residential Aged Care Facilities (RACFs) play an important role in the care of a group of older Australians who are rapidly increasing in numbers. They are often frail, dependent and are of high acuity. Demand for clinical care of RACF residents has increased, and there has been a shift in the characteristics of staff who care for them. It is now common practice in High Care facilities that the majority of direct care is provided by Assistants in Nursing and/or Personal Carers, who have little formal training. Sydney Local Health District (SLHD) in Sydney Australia has 77 Residential Aged Care Facilities (RACFs), with 4,576 beds. Description: In 2008 a telephone triage service, Aged Care Triage (ACT), was introduced to assist RACF’s to provide care to residents in the most appropriate setting. The service is staffed by experienced registered nurses. During the period July 2009 - June 2010 this service saved 2427 emergency department presentations across the District. The Access Care Team aims to provide the best care for residents of RACFs in the most appropriate setting by offering clinical advice and arranging services to support resident's care within the RACFs. It offers a partnership between RACFs, GPs and services of SLHD, by linking medical specialists and expert hospital nurses with GPs, ACAT/MAC, Sydney District Nursing and Palliative Care, with GPs and RACF staff. The Access Care Team can arrange outreach or outpatient services for clinical issues such as ambulatory care appointments, behavioural issues, continence issues, IV antibiotic therapy, Palliative care, Wound care management. The Access Care Team also has the capacity to facilitate and coordinate transfers to the most appropriate health services, such as appropriate emergency department if required. In 2010, funding was sourced to commence an RACF Outreach service. This compliments the ACT service. The outreach model was developed to improve access to primary health care for older people residing in RACFs and for the provision of face-to-face clinical nursing services to residential aged care facilities (RACFs) during the business hours period. Three senior nurses with extensive aged health experience are employed to provide a rapid and mobile outreach service to RACFs within SLHD catchment. They attend RACFs during business hours to resolve problems and prevent transfers or facilitate transfers to the Emergency Department. Aim, Theory, Targeted Population & Stakeholders: Together with relevant stakeholders the service and promotes an outreach model into residential care that: Builds on the existing ACT Service which is a central point of contact, resource for all RACF within SLHD Utilises an existing care manual for use within facilities to support RACF staff with evidence based algorithms for clinical care Provides regular targeted and group education for RACF staff Provide clinical coaching to RACF staff with all consultations. Promote collaborative work between acute care staff, RACF staff, GPs, Allied Health staff, families and significant others across primary and secondary settings. Establish goals of care and management plan for residents seen by the RACF outreach which facilitated efficiency of review in ED Enable the management of complex residents within the RACF Promote early intervention for highly complex residents Impacts: During the period June 2016 – January 2017 the RACF outreach team provided 777 occasions of service seeing 193 residents. 166 interventions ranging from care planning, medication review, complex wound management, comprehensive geriatric assessment, behaviour management, tube management and end of life planning Facilitation of geriatrician review. These residents would otherwise been transferred to one of the Districts ED’s. This small team of nurses have been able to sustain the model over a number of years while imparting clinical education to RACF staff to empower them to provide high quality care to frail aged residents. The right care, in the right place at the right time.

Residential medication management reviews in Australian residential aged care facilities.

IntroductionDysphagia is common in people living with dementia and associated with increased risk of aspiration pneumonia, dehydration, malnutrition, and death. Treatment options are limited and the use of texture-modified food and fluids (TMF) is a widespread clinical practice. This review aimed to evaluate the evidence for TMF in dementia.MethodsA literature search using terms “dysphagia,” “texture-modified food and fluids,” “dementia,” and “aged care” was performed by using three electronic databases from 1990 to March 2017. Studies were assessed for suitability, then reviewed with data extracted, and grouped by categories of outcome measures.ResultsA total of 3,722 publications were identified, and 22 studies met the inclusion criteria. Studies were heterogeneous in design and methodology. There were no publications examining dementia exclusively; however, many subjects with dementia were included in studies of residential aged care facilities. TMF reduced the risk of aspiration seen on videofluoroscopy but not clinical aspiration and pneumonia. TMF was associated with lower daily energy and fluid intake and variable adherence.ConclusionThere is a lack of evidence for people living with dementia and in residential care facilities that TMF improves clinical outcomes such as aspiration pneumonia, nutrition, hydration, morbidity, and mortality. Adverse effects including poorer energy and fluid intake were identified.