Australian Aged Care Research Articles

Workplace violence in extreme settings: the case of aged care workers and the role of anti-violence HRM and trust of managers on intention to leave

PurposeAged-care work has become an extreme form of work. Anti-violence HRM, comprising practices to combat workplace violence, is important in an industry with widespread violence. In this paper, we employ social exchange theory to better understand the effect of anti-violence HRM and trust in the manager on perceived nurse and PCA cynicism working in Australian aged care facilities and their subsequent intention to leave.Design/methodology/approachThis study used a mixed method with two stages. Stage 1 comprised semi-structured interviews with 10 managers and 50 nurses and PCAs working in Australian aged care facilities. Stage 2 comprised a survey of nurses and PCAs with a total of 254 completed responses in Time 1 (first wave) and 225 completed responses in Time 2 (second wave).FindingsWe tested three hypotheses and reported that interestingly anti-violence HRM was positively associated with organisational cynicism. Organisational cynicism mediated the relationship between anti-violence HRM and intention to leave. Worker trust in the manager moderated the relationship between anti-violence HRM practices and organisational cynicism, such that high levels of trust in the manager increased the effect of anti-violence HRM practices to reduce organisational cynicism and subsequently reduce intention to leave.Originality/valueWe find evidence that in aged care, workers' trust in their managers is critical for effectual anti-violence HRM. We argue that implementation of HRM practices may be more complex in extreme work settings. It is crucial to study HRM in situ and understand the root of social exchange(s) as a foundation for HRM to influence employee attitudes and behaviour.

The experience of Australian aged care workers during a trial implementation of a palliative care outcomes programme.

End of life care is an essential part of the role of Australian aged care homes (ACHs). However, there is no national framework to support aged care staff in systematically identifying residents with palliative care needs or to routinely assess, respond to, and measure end of life needs. The Palliative Care Outcomes Collaboration (PCOC) is a national outcomes and benchmarking programme which aims to systematically improve palliative care for people who are approaching the end of life, and for their families and carers. The PCOC Wicking Model for Residential Aged Care was developed and piloted in four Australian ACHs. This paper reports on the qualitative findings from semi-structured interviews and focus groups conducted with ACH staff (N=37) to examine feasibility. Thematic analysis identified three overarching themes about the pilot: (i) processes to successfully prepare and support ACHs; (ii) appropriateness of PCOC tools for the ACH setting; and (iii) realised and potential benefits of the model for ACHs. The lessons presented valuable insights to refine the PCOC Wicking Model and enrich understanding of the potential challenges and solutions for implementing similar programs within ACHs in future. The results suggest that key to successfully preparing ACHs for implementation of the PCOC Wicking Model is an authentic and well-paced collaborative approach with ACHs to ensure the resources, structures and systems are in place and appropriate for the setting. The PCOC Wicking Model for Residential Aged Care is a promising prototype to support ACHs in improving palliative and end of life care outcomes for residents and their carers.

An evaluation of influenza, pneumococcal and herpes zoster vaccination coverage in Australian aged care residents, 2018 to 2022.

For older persons, vaccination mitigates the harmful impact of vaccine preventable infections. Our study objectives were to evaluate in the Victorian public sector residential aged care services (PSRACS) (1) the existence of local vaccination policies and admission assessment practices, (2) the current documented status of resident influenza, pneumococcal and herpes zoster vaccination uptake and (3) changes in documented resident vaccination uptake over time. Standardised data were annually reported by all PSRACS between 2018 and 2022. The influenza, pneumococcal and herpes zoster vaccination status of each resident was classified as vaccinated, declined, contraindicated or unknown. Annual trends in vaccination status were assessed using Spearman's correlation. In 2022, most PSRACS reported an influenza immunisation policy existed (87.1%) and new residents were assessed for their influenza vaccination status (97.2%); fewer PSRACS reported the same for pneumococcal disease (73.1% and 78.9%) and herpes zoster (69.3% and 75.6%). The median resident influenza, pneumococcal and herpes zoster (70-79 years old) vaccination uptake was 86.8%, 32.8% and 19.3% respectively. The median unknown status was 6.9%, 63.0% and 76.0% respectively. Statistical evidence of an increase in annual uptake was observed for the herpes zoster (all resident) surveillance module (rs=0.900, p=0.037). Our study showed local influenza vaccination policies and practices exist and influenza vaccination uptake was consistently high. Pneumococcal and herpes zoster vaccination uptake were lower. Quality improvement strategies that at least determine the status of those residents classified as unknown are required.

Food provision in Australian aged care homes does not meet protein needs of residents: A call for reform.

Malnutrition is common in older adults in aged care homes, partly due to inadequate protein intake. Menu planning guidelines are available however, adherence to guidelines is unknown. This study aimed to determine; (i) what are the average serving sizes of menu items provided and do they meet recommended portion sizes? (ii) does consumption from a 'typical' menu provide sufficient protein? and (iii) can substituting a 'typical' menu with high-protein options enable residents to achieve protein adequacy? This study involved 572 residents (73% female; aged 86.4 ± 7.3 years) from 60 aged-care homes in Australia involved in a 2-year cluster-randomised trial. During the trial, food intake was recorded quarterly using visual estimation of plate-waste and 42 061 foods analysed. As part of a secondary analysis of these data, portion sizes of foods were compared to guidelines by calculating the mean (95% confidence interval). Items were deemed inadequate if the upper 95% confidence interval remained below recommended portion sizes. On average 47% of breakfast and 80% of lunch/dinner items were below recommended portion sizes. Relative protein intakes, from a typical menu (most consumed foods), was 0.9 g and 0.8 g/kg body weight/day for females and males; both below recommendations. Substituting regular items with higher protein equivalents increased protein intake to 1.3 g and 1.2 g/kg body weight/day, for females and males, respectively. Aged care homes in Australia are not meeting menu planning guidelines resulting in insufficient protein being provided. Reform to menu guidelines including provision of high-protein foods, will ensure protein adequacy in older adults in aged-care homes.

An exploration of healthcare use in older people waiting for and receiving Australian community-based aged care services.

Home care packages (HCPs) facilitate older individuals to remain at home, with longer HCP wait times associated with increased mortality risk. We analyze healthcare cost data pre- and post-HCP access to inform hypotheses around the effects of healthcare use and mortality risk. Regression models were used to assess the impact of delayed HCP access on healthcare costs and to compare costs whilst waiting and in the 6- and 12 month periods post-HCP access for 16 629 older adults. Average wait time for a HCP was 89.7 days (SD = 125.6) during the study period. Wait-time length had no impact on any healthcare cost category or time period. However, total per day healthcare costs were higher in the 6 and 12 months post-receipt of a HCP (AU$61.5, AU$63, respectively) compared with those in the time waiting for a HCP (AU$48.1). Inpatient care accounted for a higher proportion of total healthcare costs post-HCP (AU$45.1, AU$46.3, respectively) compared with in the wait time (AU$30.6), whilst spending on medical services and pharmaceuticals reduced slightly in the 6 month (AU$7.1, AU$6.3) and 12 month (AU$7.2, AU$6.3) post-HCP periods compared with in the wait time (AU$7.9, AU$7.1). Increased spending post-HCP on inpatient care or non-health support afforded by HCPs may offer protective effects for mortality and risk of admission to aged care. Further research should explore the association between delayed access to inpatient care for geriatric syndromes and mortality to inform recommendations on extensions to residential care outreach services into the community to improve the timely identification of the need for inpatient care. Geriatr Gerontol Int 2023; 23: 899-905.

Cohort profile: GRACE – a residential aged care cohort examining factors influencing antimicrobial resistance carriage

BackgroundThe emergence of antimicrobial-resistant bacteria represents a considerable threat to human health, particularly for vulnerable populations such as those living in residential aged care. However, antimicrobial resistance carriage and modes of transmission remain incompletely understood. The Generating evidence on antimicrobial Resistance in the Aged Care Environment (GRACE) study was established to determine principal risk factors of antimicrobial resistance carriage and transmission in residential aged care facilities (RACFs). This article describes the cohort characteristics, national representation, and planned analyses for this study.MethodsBetween March 2019 and March 2020, 279 participants were recruited from five South Australian RACFs. The median age was 88.6 years, the median period in residence was 681 days, and 71.7% were female. A dementia diagnosis was recorded in 54.5% and more than two thirds had moderate to severe cognitive impairment (68.8%). 61% had received at least one course of antibiotics in the 12 months prior to enrolment.ResultsTo investigate the representation of the GRACE cohort to Australians in residential aged care, its characteristics were compared to a subset of the historical cohort of the Registry of Senior Australians (ROSA). This included 142,923 individuals who were permanent residents of RACFs on June 30th, 2017. GRACE and ROSA cohorts were similar in age, sex, and duration of residential care, prevalence of health conditions, and recorded dementia diagnoses. Differences were observed in care requirements and antibiotic exposure (both higher for GRACE participants). GRACE participants had fewer hospital visits compared to the ROSA cohort, and a smaller proportion were prescribed psycholeptic medications.ConclusionsWe have assembled a cohort of aged care residents that is representative of the Australian aged care population, and which provides a basis for future analyses. Metagenomic data isolated from participants and built environments will be used to determine microbiome and resistome characteristics of an individual and the facility. Individual and facility risk exposures will be aligned with metagenomic data to identify principal determinants for antimicrobial resistance carriage. Ultimately, this analysis will inform measures aimed at reducing the emergence and spread of antimicrobial resistant pathogens in this high-risk population.

P01 The Australian experience of adapting and implementing ‘To Dip or Not to Dip’ in residential aged care facilities

Abstract Objectives ‘To Dip or Not to Dip’ (TDONTD) is a behavioural intervention focused on reducing inappropriate antibiotic prescribing for urinary tract infections (UTI) by changing urine dipstick testing practice. It was adapted by the Aged Care Quality and Safety Commission from a successful initiative in England’s care homes. We describe TDONTD adaptation and evaluation of TDONTD to support improvement in UTI management in Australian residential aged care facilities. Methods Data were collected in 12 facilities, from November 2021 to July 2022. Baseline and 3 month interviews were conducted with nurse and pharmacist champions implementing TDONTD and antibiotic prescribing audits. Results Australia’s most widely accepted national guideline for assessment of residents with suspected UTI discourages urine testing in asymptomatic persons, however, is not explicit on when to (or not) perform dipstick testing in residents who do not meet minimum criteria for UTI. We adapted key resources including case-based education, clinical pathway for assessing residents for suspected UTI and antibiotic audit tool to incorporate national guideline recommendations around dipstick testing. Surveys with nurse champions of urine dipstick practice showed improved practice in the facilities related to reduced testing for asymptomatic bacteriuria (ASB) and increased use of formal protocol to guide dipstick testing practice and UTI diagnosis. Qualitative interviews with champions identified: (i) increased knowledge around ASB, clinical signs and symptoms of suspected UTI; (ii) increased confidence in not relying on dipstick testing to diagnose suspected UTI; (iii) TDONTD challenged and changed nurse perceptions of how residents present with UTI; (iv) pressure from external healthcare professional providers and family to perform dipstick testing was common; and (v) TDONTD was a feasible intervention in Australian RACF setting. Oral antibiotic prescribing for all indications, including UTI, improved with the intervention as did prescribing appropriateness for UTI treatment but not prophylaxis (Table 1). Table 1.Oral antibiotic prescriptions for UTI at baseline, 3 months and 6 monthsOral antibiotic prescriptionsBaseline (%), 1074 residents3 months (%), 1054 residents6 months (%), 634 residentsFor all indications7.95.25.1For UTI32.61.6By appropriateness (indication and duration) For UTI treatment2758100 For UTI prophylaxis61814 Conclusions We found that TDONTD supported improved clinical management of residents with suspected UTI in an Australian aged care setting. Knowledge, skills and environmental context and resources contributed towards practice change. External healthcare professional providers and family were barriers to change suggesting that education around dipstick testing should be expanded to broader community and hospital healthcare settings in Australia.

Strategies that support cultural safety for First Nations people in aged care in Australia: An integrative literature review.

The 2019 Royal Commission into Aged Care Quality and Safety highlighted the need for First Nations peoples to have improved, culturally safe care. This paper is a call to action for First Nations peoples to be involved in developing culturally safe care and services to be embedded within Australian aged care services. The first screening examined the Australian literature (peer-reviewed articles published since 2010 in English) detailing key aspects relevant to Cultural Safety for First Nations peoples supported by aged care services in Australia. The second screening assessed whether the findings of these studies aligned with the key aspects of Cultural Safety of First Nations peoples in aged care. The initial literature search yielded 198 papers, of which 13 met the inclusion criteria for the final review. Topics that required further interrogation included barriers to communication, racism and discrimination, impacts on health outcomes, health-care workforce education needs and the importance of cultural connections to Country and kin. These topics influenced the perception of First Nations peoples feeling culturally safe when supported by aged care services. The literature identified a need to recruit more First Nations peoples into the aged care workforce, involve more First Nations family and community members in aged care and retain a consistent workforce overall. Together these strategies were seen to address the barriers that continue to affect aged care provision for First Nations peoples.

‘Brainwork practices’: responsibilisation of dementia prevention in Australian aged care discourse

Abstract Successful ageing continues to be a key theme in contemporary ageing discourses, where good physical and cognitive health in older age is an individualised responsibility. This paper explores how Australian aged care stakeholder discourse contributes to constructions of self-responsibility for brain health and dementia prevention in older persons. Brain health advice messages about diet, exercise and ‘brain fitness’ by aged care stakeholders are argued to construct a moral framework of ‘brainwork practices’ to prevent or delay dementia. This study performed discourse analysis of a sample of public online aged care stakeholder documents (N = 170) to reveal three key concepts in discursive constructions of dementia. The first concept characterises dementia as a disastrous force to be opposed; the second is a biomedical concept of dementia as preventable (or able to be delayed) in a ‘successful’ older age, while the third reflects neurocultural ideas that fetishise perfect memory as the best defence against cognitive decline and dementia. Identifying this matrix of responsibilising ‘brainwork practices’ messages by aged care stakeholders makes a contribution within social gerontology to revealing neoliberal conceptions of older age as an outcome of lifestyle and consumer choices, where dementia is constructed as ‘failed’ or ‘unsuccessful’ ageing.

Technology-guided assessment of vocalisations and their diagnostic value as pain indicators for people living with dementia.

during pain assessment in persons unable to self-report, such as people living with dementia, vocalisations are commonly used as pain indicators. However, there is a lack of evidence from clinical practice regarding their diagnostic value and relationship with pain. We aimed to explore vocalisations and pain in people with dementia undergoing pain assessments in clinical practice settings. a total of 22,194 pain assessments were reviewed in people with dementia (n = 3,144) from 34 different Australian aged care homes and two dementia specific programs. Pain assessments were conducted by 389 purposely trained health care professionals and cares using PainChek pain assessment tool. Vocalised expressions were determined based on nine vocalisation features included in the tool. Linear mixed models were used to examine the relationship of pain scores with vocalisation features. Using a single pain assessment for each of the 3,144 people with dementia, additional data analysis was conducted via Receiver Operator Characteristic (ROC) analysis and Principal Component Analysis. vocalisation scores increased with increasing pain intensity. High pain scores were more likely with the presence of sighing and screaming (8 times). The presence of vocalisation features varied depending on the intensity of pain. The ROC optimal criterion for the voice domain yielded a cut-off score of ≥2.0 with a Youden index of 0.637. The corresponding sensitivity and specificity were 79.7% [confidence interval (CI): 76.8-82.4%] and 84.0% (CI: 82.5-85.5%), respectively. we describe vocalisation features during presence of different levels of pain in people with dementia unable to self-report, therefore providing evidence in regard to their diagnostic value in clinical practice.

Baseline data from the Australian PITCH study: Characteristics of home care workers providing dementia care

AbstractBackgroundPeople living with dementia increasingly prefer to live in their own home as their care needs progress. Home care workers (HCWs) are essential for supporting independent living, and need training and support on how to deliver evidence‐based and best‐practice dementia care. The home care workforce is diverse, and in Australia, the number of workers who identify as culturally and linguistically diverse (CALD) in 2020 represented 21% of the total direct‐care workforce.The Promoting Independence Through quality Care at Home (PITCH) project aims to improve outcomes for people living with dementia and their paid and family carers by co‐designing and testing an evidence‐based specialist training program for dementia care. A pragmatic stepped‐wedge cluster RCT is being conducted to evaluate the program. To date, 227 HCWs from seven home care providers across Australia have completed baseline measures.MethodHCWs completed the Strain in Dementia Care Scale (SDCS), Sense of Competence In Dementia Care – Staff (SCIDS), Dementia Attitudes Scale (DAS) and Dementia Knowledge Assessment Scale (DKAS). Associations between these measures was assessed using Pearson correlations. HCWs were grouped into CALD/non‐CALD groups based on self‐reported cultural background. ANOVAs examined group differences by CALD status.ResultFor the whole sample, SCIDS was correlated with DAS (r = 0.599, p<0.005) and DKAS (r = 0.257, p<0.005). DAS and DKAS were moderately correlated (r = 0.334, p<0.005). Nearly 30% of HCWs in our sample identified as CALD. The CALD group showed lower DAS, DKAS and SCIDS compared to the non‐CALD group (p’s<0.001). No differences were observed on SDCS (p = 0.58).ConclusionHCWs who were more knowledgeable about dementia had more positive attitudes toward dementia and a higher sense of competence in dementia care. HCWs who did not identify as CALD showed greater dementia knowledge, more positive dementia attitudes, and higher sense of competence in dementia care. Findings suggest that better dementia literacy supports more positive attitudes to dementia and sense of competence, and highlights that more targeted and specialized support may be beneficial for staff from CALD backgrounds (who comprise a high proportion of the Australian aged care workforce). Findings have implications for clinicians, researchers, policy‐makers, educators, and providers of dementia services.

Person-centred care in Australian aged care

This paper is derived from research I undertook as a part of my honours degree in nursing. My research produced a thesis that examined person-centred care in Australian residential aged-care settings. The idea for this came from my 15 years’ experience as an aged-care nurse and questions arising from my lived experience of person-centred care not being a reality for residents, families and staff despite being widely espoused in the aged-care sector. The sector in Australia is undergoing a system redesign, with proposals for a new Aged Care Act put forward this year by the Royal Commission into Aged Care Quality and Safety (RCACQS, 2021) after a review of the aged-care system between 2018 and 2021. The review looked into the prevalence of elder abuse and estimated that almost 40% of residents may have experienced emotional, physical or neglectful abuse (RCACQS, 2020a). Person-centred care could be an important concept to establish in Australian residential aged care in order to tackle the experience of abuse and embed high-quality, safe services.

Who cares about Aboriginal Aged Care? Evidence of home care support needs and use in rural South Australia.

To assess awareness, needs and use of Australian Government-funded home aged care services among Aboriginal and Torres Strait Islander Peoples from rural and remote South Australia. Mixed-method study. Four rural and remote communities with a higher proportion of Aboriginal populations (Ceduna, Port Augusta, Port Lincoln and Whyalla). Fifty Aboriginal peoples aged 50-89 years (68% females) interviewed between August 2020 and October 2021. Participant awareness, needs and unmet needs. 88% of the participants indicated they needed home care support with daily activities (median number of needs = 3; interquartile range 2-6 needs), especially housework (86%) and transportation (59%). However, only 41% of those reporting current needs were receiving home care services. The most prevalent unmet needs were allied health (87%), housework (79%), help with meals/meals preparation (76%), shopping (73%) and personal care (73%). Overall, 62% of the participants were unaware of the Commonwealth Home Support Programme, and 54% were unaware of the Home Care Packages program. Qualitative data showed participants felt there is insufficient information and public consultation about these services for older Aboriginal adults. Regular communication in group activities was the preferable approach to becoming aware of these services rather than websites, posted materials or phone calls. Further work is needed to increase home aged care service access for Aboriginal and Torres Strait Islander Peoples living in rural and remote settings. Promotion of these programmes through local group activities could facilitate access to these services and facilitate community engagement in decision-making.

An Australian aged care home for people subject to homelessness: health, wellbeing and cost–benefit

BackgroundOlder people subject to homelessness face many challenges including poor health status, geriatric syndromes, and depression, coupled with barriers in accessing health and aged care services. Many are in need of formal aged care at a younger age than the general population, yet, in Australia, specialised aged-care services to support this vulnerable cohort are limited.MethodsThis study was an evaluation of a new purpose-built aged care home for people with high care needs and who are homeless or at risk of homelessness. Over the first 12 months post-admission, the study examined: (1) changes in residents’ physical, mental, psychological and social health, and (2) the costs incurred by the study cohort, including any cost benefit derived.ResultsThirty-five residents enrolled in the study between March 2020 – April 2021. At admission, almost half of residents were within the range for dementia, the majority were frail, at high risk for falls, and had scores indicative of depression. Over time, linear mixed-effect models showed significant improvement in personal wellbeing scores, with clinically significant improvements in overall health related quality of life. Levels of physical functional independence, frailty, and global cognition were stable, but cognitive functional ability declined over time. Comparison of 12 month pre- and post- admission cost utility data for a smaller cohort (n = 13) for whom complete data were available, suggested an average per resident saving of approximately AU$32,000, while the QALY indicators remained stable post-admission.ConclusionWhile this was a small study with no control group, these preliminary positive outcomes add to the growing body of evidence that supports the need for dedicated services to support older people subject to homelessness.

Prevalence and Preventability of Adverse Medicine Events in a Sample of Australian Aged-Care Residents: A Secondary Analysis of Data from the ReMInDAR Trial.

Aged care residents are vulnerable to the harmful effects of medicines; however, data on the prevalence and preventability of adverse medicine events in aged care residents are scarce. To determine the prevalence and preventability of adverse medicine events in Australian aged care residents. A secondary analysis of data from the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial was conducted. Potential adverse medicine events were identified and independently screened by two research pharmacists to produce a short-list of potential adverse medicine events. An expert clinical panel reviewed each potential adverse medicine to determine the likelihood that the event was medicine related (based on the Naranjo Probability Scale criteria). The clinical panel assessed preventability of medicine-related events using Schumock-Thornton criteria. There were 583 adverse events due to medicines, involving 154 residents (62% of the 248 study participants). There was a median of three medication-related adverse events (interquartile range [IQR] 1-5) per resident over the 12-month follow-up period. The most common medication-related adverse events were falls (56%), bleeding (18%) and bruising (9%). There were 482 (83%) medication-related adverse events that were preventable, most commonly falls (66% of preventable adverse medicine events), bleeding (12%) and dizziness (8%). Of the 248 residents, 133 (54% of the cohort) had at least one preventable adverse medicine event, with a median of 2 (IQR 1-4) preventable adverse medicine events per resident. In total, 62% of aged care residents in our study had an adverse medicine event and 54% had a preventable adverse medicine event in a 12-month period.

Optimising the quality of clinical data in an Australian aged care and disability service to improve care delivery and clinical outcomes (OPTIMISE): Protocol for an Agile Lean Six Sigma study.

In Australia, aged care and disability service providers are legally required to maintain comprehensive and accurate clinical documentation to meet regulatory and funding requirements and to support safe and high quality care provision. However, evidence suggests poor quality clinical data and documentation is widespread across the sector and can significantly affect clinical decision-making and care delivery and increase business costs. The OPTIMISE study uses an Agile Lean Six Sigma framework to: 1) identify opportunities for optimisation of clinical documentation processes and clinical information systems, 2) implement and test optimisation solutions, and 3) evaluate outcomes post-optimisation, in a large post-acute community-based health service providing aged care and disability services in Western Australia. A three-stage prospective optimisation study will be undertaken. Stage 1 (Baseline) will measure existing clinical data quality, identify root causes of data quality issues across services, and generate optimisation solutions. Stage 2 (Optimisation) will implement and test changes to clinical documentation processes and information systems using incremental Agile sprints, and Stage 3 (Evaluation) will evaluate change in primary and secondary outcomes from baseline to 12 months post-optimisation. The primary outcome is data quality measured in terms of Defects Per Unit (DPU), Defects Per Million Opportunities (DPMO) and Sigma level. Secondary outcomes are care delivery (direct care time), clinical incidents, business outcomes (cost of quality, workforce productivity), and user satisfaction. Case studies will be analysed to understand impacts of optimisation on clinical outcomes and business processes. As of 1 June 2022, Stage 1 commenced with baseline data quality audits conducted to measure current data quality. Baseline data quality audits will be followed by user consultations to identify root causes of data quality issues. Optimisation solutions will be developed by January 2023 to inform optimisation (Stage 2) and evaluation (Stage 3). Study findings will be of interest to individuals and organisations in the healthcare sector seeking novel solutions to improve the quality of clinical data and support high quality care delivery and reduce business costs. N/A.

Exploring what matters to residents of Australian aged care facilities with the Happy Life Index: comparison of qualitative responses between pre- and mid-Covid-19 pandemic time points

PurposeThis study analysed data from a national survey of people living in Australian Residential Aged Care Facilities (RACFs) reporting on what is the best thing about where they live and suggestions for improvement. Data from prior to the Covid-19 pandemic were compared with data during the Covid-19 pandemic.MethodsQualitative data from the Happy Life Index Survey were analysed using summative content analysis to code the responses in the data sets and then organise them into categories. Once categorised, the pre-Covid-19 and mid-Covid-19 data sets were compared using descriptive statistics.ResultsA total of 4745 residents, from over 100 RACFs, provided 8512 open-text responses to at least one of the two survey questions. Pre-Covid-19 responses were compared with mid-Covid-19 responses and those trending towards relevance (5–10% change) were identified. There were both positive and negative relevant percent changes for staff number, food (general comments), and friendliness. A trending positive percentage change was observed for staff quality and the internal environment. There was a trending negative relevant percentage change for lifestyle activities, staff generally, level of contentedness, the general environment, general choice, and general views about the service.ConclusionPeople living in RACFs notice the changes in staffing levels and visitors during restrictions imposed during infectious outbreaks. During these times, they appreciate the quality of the staff attending to their needs and the quality of their food. Further exploration is needed of the value of lifestyle activities and strategies to promote feelings of contentedness and general wellbeing during times of restriction.

Relationship between residential aged care facility characteristics and breaches of the Australian aged care regulatory standards: non-compliance notices andsanctions.

To examine the relationship between structural characteristics of Australian residential aged care facilities (RACFs) and breaches of the aged care quality standards. Facility-level analysis of audits, sanctions and non-compliance notices of all accredited Australian RACFs between 2015/16 and 2018/19. Structural factors of interest included RACF size, remoteness, ownership type and jurisdiction. Two government data sources were joined. Each outcome was analysed to calculate time trends, unadjusted rates and relative risks. Non-compliance notices were imposed on 369 RACFs (13%) and 83 sanctions on 75 RACFs (3%). Compared with New South Wales (NSW), non-compliance notices were less likely in Victoria, Queensland and the Northern Territory (NT), more likely in South Australia (SA), and comparable in Western Australia (WA), Tasmania and the Australian Capital Territory (ACT). RACFs with more than 100 beds and RACFs located in remote and outer regional areas (vs. major cities) also increased the likelihood of non-compliance notices. Compared with NSW, sanctions were less likely in Victoria, Queensland, NT and WA and comparable in SA, Tasmania and ACT. Additionally, the likelihood of sanctions was higher for RACFs with more than 40 beds. For both non-compliance notices and sanctions, no significant relationship was found with RACF ownership type. We partially confirmed other Australian findings about the relationship between RACF structural characteristics and regulatory sanctions and reported new findings about non-compliance notices. Routine and standardised public reporting of RACF performance is needed to build trust that Australia's latest aged care reforms have led to sustained quality improvements.

‘Vulnerable Monsters’: Constructions of Dementia in the Australian Royal Commission into Aged Care

This paper argues that while regulatory frameworks in aged care authorise restraints to protect vulnerable persons living with dementia from harm, they also serve as normalising practices to control challenging monstrous Others. This argument emerges out of an observed unease in aged care discourse where older people living with dementia are described as ‘vulnerable’, while dementia behaviours are described as ‘challenging’. Using narrative analysis on a case study from the Final Report of the Australian Royal Commission into Aged Care Quality and Safety (RCAC), this paper investigates how the RCAC (re)produced constructions of persons with dementia as ‘vulnerable monsters’. Drawing upon monstrous theory about ‘unruly and leaky’ bodies, extracts from the case study reveal how the RCAC repeated and reinforced monstrous constructions of dementia. Dementia behaviours, particularly ‘wandering’, were constructed through a dehumanising crisis frame that produced ‘challenging’ bodies and legitimised ‘last resort’ normalising practices, such as physical and chemical restraints. In failing to resist monstrous constructions of dementia behaviours, the RCAC accepted and authorised a regime of scaled responses leading to restrictive practices for control of challenging bodies in aged care. Although dementia care and restrictive practices received substantial attention in the RCAC, this paper reveals a missed opportunity for deeper review of institutionalised use of restraints that has relevance for ongoing reform of Australian aged care following conclusion of the RCAC.

Development of a Multivariable Prediction Model for Risk of Hospitalization With Pressure Injury After Entering Residential Aged Care.

Although largely preventable, pressure injury is a major concern in individuals in permanent residential aged care (PRAC). Our study aimed to identify predictors and develop a prognostic model for risk of hospitalization with pressure injury (PI) using integrated Australian aged and health care data. National retrospective cohort study. Individuals ≥65years old (N= 206,540) who entered 1797 PRAC facilities between January 1, 2009, and December 31,2016. PI, ascertained from hospitalization records, within 365days of PRAC entry was the outcome of interest. Individual, medication, facility, system, and health care-related factors were examined as predictors. Prognostic models were developed using elastic nets penalized regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination out-of-sample. Within 365days of PRAC entry, 4.3% (n= 8802) of individuals had a hospitalization with PI. The strongest predictors for PI risk include history of PIs [sub-distribution hazard ratio (sHR) 2.41; 95% CI 1.77-3.29]; numbers of prior hospitalizations (having ≥5 hospitalizations, sHR 1.95; 95% CI 1.74-2.19); history of traumatic amputation of toe, ankle, foot and leg (sHR 1.72; 95% CI 1.44-2.05); and history of skin disease (sHR 1.54; 95% CI 1.45-1.65). Lower care needs at PRAC entry with respect to mobility, complex health care, and medication assistance were associated with lower risk of PI. The risk prediction model had an AUC of 0.74 (95% CI 0.72-0.75). Our prognostic model for risk of hospitalization with PI performed moderately well and can be used by health and aged care providers to implement risk-based prevention plans at PRAC entry.