Residential Aged Care Facilities Staff Research Articles

Engaging dental professionals in residential aged-care facilities: staff perspectives regarding access to oral care

The limited access to oral care for older people living in residential aged care facilities (RACFs) has been noted repeatedly in the literature. The aim of this study was to explore RACF staff perspectives on how to engage dental professionals in the provision of oral care for RACF residents. Semi-structured interviews were conducted with 30 staff from six purposively selected RACFs located in high socioeconomic areas to gain understanding of the multidimensional issues that influenced the engagement of dental professionals from a carer perspective. Analysis revealed that staff perceived tensions regarding affordability, availability, accessibility and flexibility of dental professionals as significant barriers to better oral care for their residents. Participants raised a series of options for how to better engage dental professionals and reduce these barriers. Their ideas included: the engagement of RACF staff in collaborative discussions with representatives of public and private dental services, dental associations, corporate partners and academics; the use of hygienists/oral health therapists to educate and motivate RACF staff; the promotion of oral health information for troubleshooting and advice on how to deal with residents' dental pain while waiting for support; the encouragement of onsite training for dental professionals; and the importance of gerodontology (geriatric dentistry). Findings highlighted the need to explore alternative approaches to delivering oral care that transcend the model of private clinical practice to focus instead on the needs of RACFs and take into account quality of end-of-life oral care.

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study

Objective(s)To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs).Design and settingThe study used qualitative methods to...

General practice and residential aged care: A qualitative study of barriers to access to care and the role of remuneration.

More than 169,000 people live in residential aged care facilities (RACFs). As people age they use health services, particularly general practitioner (GP) services, more frequently but many GPs do not attend patients in RACFs. To examine GPs' perceptions of barriers to providing care to patients in RACFs. This study was conducted in June 2014 in the Bayside Medicare Local (BML) region in Victoria, Australia; all participants were drawn from this region. Two focus groups (FGs) were conducted. One was for GPs (n=5) that have a specific interest in practicing in RACFs, the other with RACF staff (n=8) representing public, private, and not-for-profit aged care providers. Results were presented to the Royal Australian College of General Practitioners (RACGP) National Standing Committee for General Practice Advocacy and Support for feedback and validation of the findings against national perspectives of the effect of remuneration on the provision of GP services in RACFs. Remuneration problems are a barrier to the provision of GP services to patients in RACFs. These problems can be grouped into: direct remuneration, opportunity cost, additional administrative burden, and unremunerated work. GPs' perceptions of the effects of these problems on willingness to practice in RACFs are described. Innovative models of remuneration for GPs attending RACFs are needed to ameliorate the problems identified. Such models need to capture and pay for activities that are time consuming but often unremunerated.

Advanced restorative dentistry - a problem for the elderly? An ethical dilemma.

The type of dental restorations taken into old age may have an adverse effect on the quality of life of the elderly. Root caries and dry mouth increase in prevalence with age and may precipitate the breakdown of remaining natural and restored teeth. At present the availability of dental personnel and facilities in residential aged care facilities (RACFs) is limited, often non-existent, and the elderly living at home may be unable to easily gain access to dental care. Thus, the provision of appropriate and timely dental treatment may not occur, resulting in prolonged pain and suffering. It is important that, as our elderly population increasingly retain natural teeth into advanced old age, appropriate funds are made available to ensure their dental health is maintained. A lack of early intervention to arrest dental disease may result in life-threatening medical consequences in the elderly, such as ventilator assisted pneumonia or the need for a general anaesthetic and possible associated medical risks. Significant local disease, such as osteonecrosis, may also result from a lack of appropriate dental intervention. The necessity to remove questionable teeth prior to irradiation for neoplastic disease or bisphosphonate prescription for neoplastic disease or severe osteoporosis emphasizes the need for regular dental care. In contrast, extensive dental restorative treatment for younger people may have benefits, such as optimal dental aesthetics and oral function, but in older individuals careful consideration should be given to select the most appropriate treatment modality so that adverse situations can be avoided or their resolution simplified should they occur later when the individual is compromised or in a RACF. This may mean the use of conservative dental restorative materials and an avoidance of complex restorative options which may be difficult for the individual or RACF staff to maintain. Some years after receipt of their complex restorations they may be unable to cope with the operative demands and financial burden of resolving their deteriorating dental situation and so complex implant-born structures and precision removable prostheses should probably be avoided for those individuals contemplating entering a care situation. Therefore, the timing of the provision of complex dentistry poses an ethical dilemma.

Nurse-led ED support for Residential Aged Care Facility staff: An evaluation study

ObjectivesTo evaluate the impact of a nurse-led telephone support service to Residential Aged Care Facilities (RACFs) on a range of measures relating to the transfer of acutely unwell residents to the Emergency Department (ED) of a large tertiary referral hospital in New South Wales, Australia over a 9 month period. MethodsA pre- and post-intervention design determined the impact of the telephone service, associated clinical guidelines and education. Data from 4 intervention RACFs using the nurse-led telephone service were compared with 8 control RACFs. Data included the older patient's triage category, presenting problem(s), transfer rates from RACFs, ED admissions, and overall hospital length of stay. Interviews and focus groups with staff from RACFs and EDs were conducted to ascertain their experiences. ResultsReduced presentations of older people to the ED from the 4 pilot RACFs occurred. High levels of satisfaction among staff in RACFs were reported.

Silent and suffering: a pilot study exploring gaps between theory and practice in pain management for people with severe dementia in residential aged care facilities.

BackgroundPain is common in older people, particularly those in residential aged care facilities (RACF) and those with dementia. However, despite 20 years of discourse on pain and dementia, pain is still undetected or misinterpreted in people with dementia in residential aged care facilities, particularly those with communication difficulties.MethodsA topical survey typology with semistructured interviews was used to gather attitudes and experiences of staff from 15 RACF across Northern Sydney Local Health District.ResultsWhile pain is proactively assessed and pain charts are used in RACF, this is more often regulatory-driven than patient-driven (eg, prior to accreditation). Identification of pain and need for pain relief was ill defined and poorly understood. Both pharmacological and non-pharmacological regimes were used, but in an ad hoc, variable and unsystematic manner, with patient, staff, and attitudinal obstacles between the experience of pain and its relief.ConclusionA laborious “pain communication chain” exists between the experience of pain and its relief for people with severe dementia within RACF. Given the salience of pain for older people with dementia, we recommend early, proactive consideration and management of pain in the approach to behaviors of concern. Individualized pain measures for such residents; empowerment of nursing staff as “needs interpreters”; collaborative partnerships with common care goals between patients where possible; RACF staff, doctors, and family carers; and more meaningful use of pain charts to map response to stepped pain protocols may be useful strategies to explore in clinical settings.

Decision to transfer to hospital from the residential aged care setting: a systematic review of qualitative evidence exploring residential aged care staff experiences

Objectives To determine the best available evidence on residential aged care facility staff experiences of decision-making at the time of a resident deterioration, and to explore the factors that influence decisions to transfer to the emergency department. Inclusion criteria Types of participants All levels of residential aged care facility nursing and care staff were included, namely, registered nurses, enrolled nurses and personal care attendants. Phenomena of interest This meta-synthesis explores the experiences of residential aged care facility staff in decision-making when a resident’s health deteriorates, including factors that impact on staff decisions to transfer residents to the emergency department. Types of studies Primarily qualitative studies were included in the review. Studies incorporating surveys were also included if they reported in sufficient detail the analysis of qualitative data gathered through open-ended questions. Search strategy Key databases including CINAHL, Medline and Embase were searched. Studies were limited to English language papers published between the years 1989, when a foundational study into RACF staff decision-making was undertaken and 2011.when the database search was undertaken. Methodological quality Seventeen studies were considered to be of sufficiently sound methodological quality after being critiqued using the critical appraisal criteria in the Joanna Briggs Institute – Qualitative Assessment and Review Instrument (JBI-QARI). There was considerable variation in the quality of the studies; excellent quality (n=8); very good quality (n=2); good quality (n=6); and reasonable quality (n=1). Data collection Data were extracted using the standardized data extraction tool from JBI-QARI for interpretive and critical research. Data synthesis The data were synthesized using the Joanna Briggs Institute approach of meta-synthesis by meta-aggregation using JBI-QARI. Results Seventeen studies were included in the review. Findings were aggregated into five synthesized findings. The syntheses indicate that several factors influence decisions to transfer, including: limited staffing capacity to assess and manage residents on-site, fear related to working outside one's capacity, isolation from multidisciplinary support and healthcare resources, communication challenges between key decision makers, limited ability to rely on early planning documents and variable perceptions regarding the complexity of care that can be provided in the residential aged care setting. Conclusions Residential aged care facility staff play a key role in decision-making at the time of a resident’s deterioration. Multiple factors influence decisions to transfer to the emergency department rather than to continue care on site, including limited flexibility in staffing capacity, poor access to multidisciplinary support, difficulties in discussing a resident’s deterioration with other decision makers and fear of working outside of their scope of practice.

Design challenges for electronic medication administration record systems in residential aged care facilities: a formative evaluation.

Electronic medication administration record (eMAR) systems are promoted as a potential intervention to enhance medication safety in residential aged care facilities (RACFs). The purpose of this study was to conduct an in-practice evaluation of an eMAR being piloted in one Australian RACF before its roll out, and to provide recommendations for system improvements. A multidisciplinary team conducted direct observations of workflow (n=34 hours) in the RACF site and the community pharmacy. Semi-structured interviews (n=5) with RACF staff and the community pharmacist were conducted to investigate their views of the eMAR system. Data were analysed using a grounded theory approach to identify challenges associated with the design of the eMAR system. The current eMAR system does not offer an end-to-end solution for medication management. Many steps, including prescribing by doctors and communication with the community pharmacist, are still performed manually using paper charts and fax machines. Five major challenges associated with the design of eMAR system were identified: limited interactivity; inadequate flexibility; problems related to information layout and semantics; the lack of relevant decision support; and system maintenance issues. We suggest recommendations to improve the design of the eMAR system and to optimize existing workflows. Immediate value can be achieved by improving the system interactivity, reducing inconsistencies in data entry design and offering dedicated organisational support to minimise connectivity issues. Longer-term benefits can be achieved by adding decision support features and establishing system interoperability requirements with stakeholder groups (e.g. community pharmacies) prior to system roll out. In-practice evaluations of technologies like eMAR system have great value in identifying design weaknesses which inhibit optimal system use.

Referrals to hospital emergency departments from residential aged care facilities: Stuck in a time warp

This research aimed to describe the number and type of residents admitted to emergency departments (EDs) over 2 years; and to explore nurses’ perceptions of the reasons why residential aged care facility (RACF) residents are referred to EDs. The research objective was addressed in a retrospective exploratory study using data on admissions to EDs from RACFs (N = 3,094) at the participating organisation over a 2-year period, and interview data on seven RACF and four ED nurses’ perceptions of the issues involved. Most residents presenting at EDs required urgent medical attention. Major themes identified by RACF and ED nurses included issues related to staff competency, availability of general practitioners, lack of equipment in RACFs, residents and family members requesting referrals, communication difficulties, and poor attitudes towards RACF staff. There is a need to use strategies to detect residents whose conditions are deteriorating and treat them promptly in RACFs.

TALKING ABOUT END OF LIFE: MARKETING ADVANCE CARE PLANNING TO RESIDENTIAL AGED CARE FACILITIES

BackgroundOf the 143 932 Australians who die each year, 10% die in residential aged care facilities (RACFs). 25% of these deaths occur within 6 months of admission. Frequently residents are...

Quality of advance care planning policy and practice in residential aged care facilities in Australia

ObjectivesTo assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes...

Early treatment of obesity not to refine arthroplasties in patients with osteoarthritis

ext.– Managing the elderly involves all disciplines of Medicine, ursing and Allied Health. The World Health Organization has lready identified poor oral and dental health in the elderly as n emerging health issue; however, little progress has been made. here is an urgent need for a greater understanding of the impliations of poor oral health to be appreciated by all health care orkers. Apart from the systemic consequences of poor oral health ny resultingpainanddiscomfort canbedevastating, compounding sychosocial issues, disrupting family dynamics, frustrate carers nd Residential Aged Care Facility staff and thwart harmonious elationships amongst residents. As appearance, function and comort suffers so may an elderly person’s self esteem and confidence. roviding appropriate oral and dental care for the elderly is not bout providing expensive contemporary dental treatment. Rather t is about understanding an older person’s functional needs and ddressing oral health education for the aged, their family or carer nd those involved in delivering care in Residential AgedCare Facilties. We cannot allow oral and dental health deficits to lead to ncreased morbidity and mortality. A clean and healthy mouth is ssential to limit the potential for aspirational pneumonia arising rom oral and dental neglect in one of the most vulnerable cohorts n the community. isclosure.– No significant relationships. eference [1] Petersen, et al. Global oral health of older people – call for public health action’ community. Dental Health 2010;27(Supplement 2):257–68.

Acceptability and feasibility of end‐of‐life care pathways in Australian residential aged care facilities

To investigate the acceptability and feasibility of using end-of-life (EOL) care pathways in residential aged care facilities (RACFs). Multistage action research approach involving interviews, surveys and prospective audits of deaths and EOL care pathway use among residents and staff of RACFs and associated general practitioners from 14 RACFs in Victoria and South Australia between April 2009 and July 2010. Introduction of EOL care pathways. Evidence of acceptability was determined by the rate of pathway use in RACFs and through feedback from RACF managers, staff and GPs. Evidence of feasibility was determined by reductions in transfers to hospital for symptom management before death, length of time on pathways, and whether care was consistent with best practice at EOL. The use of EOL care pathways across the RACFs fell into low-, moderate- and high-uptake groups (for 10%, 34% and 68% of all deaths at the facility, respectively). Feedback from RACF staff and GPs indicated that acceptability was critical to successful implementation. The use of EOL care pathways demonstrated improvements in care, sometimes over extended periods. There were fewer unnecessary admissions to hospital before death, although not all RACF staff and GPs were aware of the project. EOL care pathways are feasible strategies for delivering EOL care consistent with best practice. However, their introduction into Australian RACFs needs to include strategies to facilitate acceptability by RACF staff and GPs.

Dementia, sexuality and consent in residential aged care facilities

Sexual self-determination is considered a fundamental human right by most of us living in Western societies. While we must abide by laws regarding consent and coercion, in general we expect...

Beyond the ‘tick and flick’: facilitating best practice falls prevention through an action research approach

To examine residential aged care facility staff views on using falls risk assessment tools and the implications for developing falls prevention practices in the context of an action research project. Falls risk assessments play an important role in care planning by identifying and monitoring aged care facility residents most at risk of falls. Yet while such assessments are recommended in falls prevention best practice guidelines, there is little published research that examines staff procedures and views related to conducting falls risk assessments. Falls risk assessments were undertaken in the context of an action research project. Twelve staff members from two residential aged care facilities (RACFs) in Tasmania formed a single Falls Action Research Group, which met 22 times over a year, providing the study's qualitative data. During this time, key group members assessed 178 residents using a new falls risk assessment tool (FROP-Resi). According to group members, facilities evolved from a 'tick-and-flick' approach to falls risk assessment to a more individualised, face-to-face assessment process. Group members perceived the process to be more meaningful and enjoyable for staff involved in the assessment process resulting in higher quality of assessments and leading to improved levels of falls awareness among staff, residents and family caregivers. An action research process is useful for facilitating a new approach to falls risk assessments, engaging aged care facility staff with falls prevention and prompting improvements in falls prevention practices. RACFs need to provide opportunities for staff to meet regularly to discuss practice, identify issues and take action. By doing so, staff can engage meaningfully with best practice activities such as optimising falls risk assessment processes.

Formative and process evaluation of a healthcare-associated infection surveillance program in residential aged care facilities, Grampians region, Victoria

In 2010, a standardised healthcare associated infection surveillance program was implemented and evaluated in 30 residential aged care facilities (RACF) located in the Grampians rural region, Victoria. High level care residents were monitored for trachea-bronchitis, cellulitis, conjunctivitis, gastroenteritis and symptomatic urinary tract infections. Infection data was collected and reported by RACF staff or infection control (IC) consultants. ‘Infections’ reported by RACF staff were confirmed or excluded by an IC consultant after reviewing medical records. Of the 297 true infections, 89.9% were reported by RACF staff. IC consultants excluded 206 ‘infections’ reported by RACF staff. Eight infections were detected by IC consultants after checking microbiology reports. The sensitivity and positive predictive value of data reported by RACF staff was calculated as 97.1% and 56.5% respectively. The average time for IC consultants to retrospectively check data reported by RACF staff was 2.2 h month –1 . Over 6 months, the time taken by one regional IC consultant to follow up data queries was 11 h. The evaluation of the pilot HAI surveillance programdemonstrated that the collection, collation and analysis of accurate infection data in the participating RACF can be difficult and resource intensive. If the programis to continue as currently structured, the identified issues associated with data validity and limited resources will need to be addressed.

A systematic review on the experiences of Residential Aged Care Facility staff decision making regarding the transfer of residents to Emergency Departments.

Review question/objective The objective of this review is to synthesise the best available evidence on experiences of RACF staff decision making regarding the transfer of residents to the Emergency Department. Specifically, the review question is: what are the experiences of RACF staff who have been involved the decision to transfer residents to an emergency department? Inclusion criteria Types of participants This review will consider international publications that focus on RACF staff involved in decisions regarding the transfer of residents from the RACF to the ED. All RACF nursing and care staff will be considered including, Registered Nurses RN, Enrolled Nurses EN, Personal Care Attendants PCA and Licensed Practice Nurses LPN. However, due to the ambiguity in nomenclature, no terms for RACF staff will be used in the search criteria and instead the reviewers will identify whether the sample focuses on RACF staff in the sifting phase. Phenomena of interest The phenomena of interest for this review are the experiences of RACF staff decision making regarding the transfer of residents to the Emergency Department including the experiences of the facilitators and barriers to providing care for residents within the RACF when a resident’s health deteriorates. These experiences may refer to the following issues described already in the existing literature: limited access to medical review, the influence of family and resident preferences, the requirement to follow facility transfer protocols, fear of litigation, difficulties identifying the cause of the resident’s deterioration, communication difficulties and the influence of a skill mix. Context The context for this systematic review is the RACF, which are defined as facilities that provide both permanent accommodation and the provision of personal care and nursing services. 3 Studies referring to nursing homes, long-term care settings and skilled nursing facilities will be included. Studies that are undertaken in the community or the acute care setting will be excluded because the focus in on decision-making within the RACF setting. Studies using other descriptions of RACF such as low care facilities, assisted living facilities, homes for the elderly will be critiqued to establish whether they met our definition for inclusion.

Resuscitation of out-of-hospital cardiac arrests in residential aged care facilities in Melbourne, Australia

IntroductionCPR in patients in residential aged care facilities (RACF) deserves careful consideration. We examined the characteristics, management and outcomes of out-of-hospital cardiac arrest (OHCA) in RACF patients in Melbourne, Australia. MethodsThe Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs occurring in RACFs in Melbourne. The characteristics and outcomes were compared to non-RACF patients in the VACAR. ResultsBetween 2000 and 2009 there were 30,006 OHCAs, 2350 (7.8%) occurring in a RACF.A shockable rhythm was present in 179 (7.6%) patients on arrival of paramedics of whom bystander CPR had been performed in 118 (66%); 173 (97%) received an EMS attempted resuscitation. ROSC was achieved in 71 (41%) patients and 15 (8.7%) patients survived to leave hospital. Non shockable rhythm was present in 2171 patients (92%) of whom 804 (37%) had an attempted resuscitation by paramedics. ROSC was achieved in 176 patients (22%) and 10 patients (1.2%) were discharged alive. Survival from OHCA occurring in a RACF was less than survival in those aged >70 years of age who suffered OHCA in their own homes (1.8% vs. 4.7%, p=0.001). On multivariable analysis, witnessed OHCA (OR 3.0, 95% CI 2.4–3.7) and the presence of bystander CPR (OR 4.6, 95% CI 3.7–5.8) was associated with the paramedic decision to resuscitate. ConclusionResuscitation of patients in RACF is not futile. However, informed decisions concerning resuscitation status should be made by patients and their families on entry to a RACF. Where it is appropriate to perform resuscitation, outcomes may be improved by the provision of BLS training and possibly AED equipment to RACF staff.

Report of an evaluation of a Nurse-led Dementia Outreach Service for people with the behavioural and psychological symptoms of dementia living in residential aged care facilities

This paper describes the implementation and evaluation of a Dementia Outreach Service (DEMOS). The service is led by the first Nurse Practitioner in Dementia Care in the State of Queensland in Australia and is highly innovative in terms of its mode of delivery. The evaluation took place due to a perception that new models such as the DEMOS often fail to gain momentum due to a lack of data on their effectiveness and efficiency. The parameters of the project were to evaluate the extent to which the DEMOS met its key deliverables, focusing specifically on outcomes for residential aged care facilities (RACF) residents and staff. The study involved both quantitative and qualitative data collection. Qualitative data was collected through interviews, focus groups and reflective journals. A survey which was administered at three stages of the 12 months of the study was the main source of quantitative data. Additional statistical data was collected from relevant healthcare providers. Twenty RACFs within a specific health service district participated in the study. This included an intervention group of 7 facilities (which received the service) and a control group of 13. A total of 320 RACF staff participated in Stage 1 of the study, although due to staff attrition this had reduced to 153 (54.6%) at Stage 3. Attrition rates were much lower in the 7 intervention facilities, with 67.9% of the original sample remaining at Stage 3. To augment the quantitative data collected as above, drawing on a range of qualitative techniques the researchers canvassed the perceptions, thoughts and opinions of differing stakeholders. The qualitative data proved extremely valuable in confirming the success of DEMOS. KEY SUCCESS AREAS: Increased self-confidence among staff in dealing with residents with dementia; reduced stress among staff; reductions in the instances of difficult behaviours; reduced referrals to acute sector services; high levels of satisfaction among RACF management regarding DEMOS; and a process of continuous improvement of DEMOS based on stakeholder feedback. Recommendations for the future directions of the service include: The continued support and expansion of DEMOS; An increase in the DEMOS service portfolio to actively assist facilities to change the culture of care amongst RACF carers; and Showcasing of DEMOS as an example of 'best practice' in dementia care to argue the need for provision of additional Nurse Practitioners specializing in dementia care.

A residential aged care end-of-life care pathway (RAC EoLCP) for Australian aged care facilities

The objective of this study was to develop, implement and evaluate an end-of-life (terminal) care pathway and associated infrastructure suitable for Australian residential aged care facilities that improves resident and health system outcomes. The residential aged care end-of-life care pathway was developed by a multidisciplinary collaboration of government and non-government professionals and incorporated best clinical management for dying residents to guide care and increase palliative care capacity of generalist staff. Implementation included identifying and up-skilling Link Nurses to champion the pathway, networking facilities with specialist palliative care services, delivering education to generalists and commencing a Palliative Care Medication Imprest System in each facility. The primary outcome measure for evaluation was transfer to hospital; secondary measures included staff perceived changes in quality of palliative care provided and family satisfaction with care. Results indicated that the pathway, delivered within a care framework that guides provision of palliative care, resulted in improved resident outcomes and decreased inappropriate transfers to acute care settings.