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The Advantages of Nursing in Aged Care

Nurse reviewing policies on a tablet

Historically there were negative views of the Aged Residential care setting but these have changed, and aged care has changed! Aged Care is Health Care!

Nursing is Aged Care is complex and the ongoing relationship with those needing clinical support is rewarding. This is especially true when compared with the episodic brief interactions that occurs in acute services.

Working in aged residential care in New Zealand offers registered nurses a rewarding career pathway and meaningful career choice. This environment provides the opportunity to make a real difference in the lives of older adults, delivering compassionate, person-centered care that enhances quality of life. For nurses, it’s a chance to develop high level clinical skills, build strong trusting relationships with residents, fostering a sense of community and belonging.

Aged care settings also offer diverse clinical experiences, from managing multiple co-morbidities. This includes the clinical oversight and management of chronic conditions through to supporting palliative care, and ensuring nurses develop their skills while leading care teams. The sector relies on teamwork and collaboration, creating a positive work atmosphere where nurses feel valued and empowered. Additionally, New Zealand’s aged care sector is committed to ongoing professional development, ensuring nurses stay current with best practices while using leading industry technology.

Work-life balance can be better in aged care compared to high-pressure hospital settings, with more predictable hours and a focus on holistic well-being. The sector also offers opportunities for leadership and specialization, making it an attractive career path. Overall, working in aged residential care combines professional growth with the fulfilment of caring for some of society’s most vulnerable members. This makes it an appealing environment for registered nurses seeking purpose, work satisfaction through ongoing therapeutic relationships and stability.

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The coming of age: Aged residential care nursing in Aotearoa New Zealand in the times of COVID-19

The Nursing Leadership Group (NLG) is the recognised voice of aged care nursing. The following article written by the NLG which includes HCSL’s very own Director, Gillian Robinson BN, RN has been published in the Nursing Praxis – Journal of Professional Nursing Special Issue: Nursing response to COVID-19 in Aotearoa New Zealand

The coming of age: Aged residential care nursing in Aotearoa New Zealand in the times of COVID-19

For years aged care nursing has been largely overlooked and marginalised from mainstream healthcare. COVID-19 brought both aged residential care and nursing into sharp focus for Aotearoa New Zealand. This paper provides a commentary on the work of executive nurses within the Nursing Leadership Group of the New Zealand Aged Care Association as COVID-19 spread into some ARC facilities in early 2020 and threatened the health and wellbeing of many residents and nurses. The group influenced the agenda and implementation of policies for Aged Residential Care and brought the voice of nursing and residents of aged care to the forefront at national and regional levels.

CLICK BELOW TO DOWNLOAD THE FULL ARTICLE.

Aged residential care nursing in Aotearoa

Frances Hughes, PhD, RN, Clinical Director, Oceania, Auckland
Anna Blackwell , PGDip, RN, Nursing Director/Owner, Cook Street Nursing Care Centre, Palmerston North
Tanya Bish, MN(Hons), BCom, RN, Clinical Director, Metlife Care, Auckland
Cheyne Chalmers, MMgt, RN, Chief Operating Officer, Ryman Healthcare, Christchurch
Katherine Foulkes, PGDip, RN, Clinical Services Director, Bupa, Auckland
Lynda Irvine, RN, Head of Clinical Services, Summerset Group Holdings Ltd, Auckland
Gillian Robinson, BN, RN, Director, Health Care Compliance Solutions Ltd, Christchurch
Rhonda Sherriff, RN, Managing Director, Chatswood Retirement Village, Christchurch
Virginia Sisson, PGCert, RN, Operations Manager, The Selwyn Foundation, Auckland

Reference:  Hughes, F. A., Blackwell, A., Bish, T., Chalmers, C., Foulkes, K., Irvine, L., Robinson, G., Sherriff, R., & Sisson, V. (2021).  The coming of age: Aged residential care nursing in Aotearoa New Zealand in the times of COVID-19. Nursing Praxis in Aotearoa New Zealand, 37(3), 25-29.

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Spiritual care and Pastoral Care

As we age, the need for spiritual care and pastoral care often come to the fore.  This is particularly so as people near the end of their life.  The need for comfort and peace of mind on a holistic basis.  Let’s firstly lets define the difference between these two concepts.

Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.

For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.

A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.

To read more on this topic go here.

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Audit Tips for Clinical Documentation

Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents include:

  • Age Related Residential Care (ARRC) contract
  • NZS 8134:2008 Health and Disability Services Standards
  • Clinical best practice (EBP) guidelines – eg; Lippincott
  • The Code of Health & Disability Consumers Services Rights 1996

Clinical documentation errors of any type noted during audits will result in partial attainments at best.  This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.

Below are some of the common compliance gaps which relate to clinical documentation:

General compliancegapsMissed signatures off notations.Not dated.Not signed by the author with a full signature.No designation written with signature.Not legible.Inconsistent structure of resident files.Unclear or unsecured archiving of documents.Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.
Initial assessmentsincluding InterRaiNot completed within time-frames defined in ARRC.Baseline recordings at time of admission not recorded.Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.Failure to re-assess for each period of admission eg; respite care.
Clinical riskAssessment not describing risk.Risk not reflected in care plan interventions.Lack of risk reviews.Level of risk noted in interRai assessments not included in care planning
Progress notesNot recorded in on a shift by shift basis.Lack evidence of regular registered nurse input.Writing beyond the bottom line of the page.Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).Lack evidence of interventions being implemented.Lack evidence of RN response to clinical symptoms reported by care staff.Lack of evidence of rationale for PRN medication administration or the resulting effect.
Short TermCare PlansNot developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.Not recorded as resolved or transferred to Long Term Care Plan.Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.
Long TermCare Plan (LTCP)Not reflective of all presenting potential and actual medical / clinical problems.Not documented within 3 weeks of the date of admission (ARRC requirement).Not changed at the time of health status / functional change.Interventions not reflective of each medical diagnosis.Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.Frequency of clinical assessment for each actual clinical presentation eg; pain.Do not clearly indicate the level of function, assistance required for each component of care / support.Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services             for the elderly etc.
Care PlanEvaluationsReview of care plans not reflecting changes in residents health status as they occur.Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.Not completed within ARRC defined time-frames (at least six monthly).
Multi-DisciplinaryInputLack evidence of MDT input into care plan reviews and/or evaluations.Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical           consultation notes however not evidenced as having been done.Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.
Policy andproceduresNot consistent with service delivery as noted in clinical documentation.

Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.

If you have any comments to make about this article, please contact us here.

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Workplace Culture

Workplace culture is a term bandied around a lot but what does it actually mean and how can it be measured?  When I ask staff at facilities during training sessions what they see their point of difference is, they frequently reply saying ‘we’re friendly’, or ‘we care’ or ‘we provide a homely environment’.  While these are all nice to have, they would actually be expected as a basic standard.  They are not specific and not anything different to the care facility down the road.

Mary Barra, Chairwoman and CEO of General Motors (GM) states that at GM, they prefer to talk about behaviours rather than culture as behaviours can be changed very quickly and are apparent straight away. She talks about the need for rapid change with the inclusion of technology and advancements in artificial intelligence being used more frequently.  While those are starting to be present in some aged residential care settings, what is true of both GM and aged care is rapid change and the need to adapt quickly.  This isn’t going to happen by accident and needs clear direction, guidance, leadership and engagement of all those involved.

Mary Barra also refers to bringing products to market that bring people freedom, rather than talking about cars or transportation. She focuses on the outcome for their clients.   What is the key outcome you’re wanting to provide for those in your environment and how is that defined in your values?  How is it implemented by your staff and how do you measure success on those outcomes?

A managers oath as I’ve mentioned before is a good place to start in defining the governance or leadership direction of organisations. Values and key performance indicators (KPIs) or quality objectives / measures need to align to this.To ensure consistent progress regular review of those KPIs or quality measures needs to occur and acted on according to the outcomes.  Policies and procedures to guide consistent best practice are an important part of ensuring clear direction for staff while setting parameters for performance.  Information reduces confusion and promotes change. Practice creates confidence not only in the staff but also in the resident and those observing their care.

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How friendly are nurses?

How friendly are nurses? I would generally say nurses are very friendly however we frequently see articles in nursing journals of bullying in the workplace.

I pondered this while attending the Global Speakers Summit in Auckland recently.  I was over-whelmed by the friendliness of the speakers there, many of whom are very well known internationally. It was a level of friendliness I haven’t observed at the many nursing conferences I’ve attended and certainly gives an opportunity to reflect and see how this can be improved.

I asked a nursing colleague about this and asked her for her opinion. Her response was ‘that’s why speakers are successful and nurses struggle. The lack of genuine connection and sharing.’  She went on to say ‘nurses have been eating their young for years‘. She added that nurses would do well to build each other up and celebrate success not labour struggles.

At the Speakers Summit, I don’t recall a single time when a person walked in my direction without a smile and stopping to exchange pleasantries. Some of these people I knew or had met previously but many were first time encounters. Their responses went beyond pleasantries and extended to engage in a conversation that created connection and sharing and a sense of belonging. A pleasant change and one I hope we can do more to foster in nursing. Surely our patients and their families would benefit hugely if we can all be a little more compassionate and patient, and show genuine interest in each other.

A colleague offered the following explanation as to why nurses rush and lack apparent friendliness at times. ‘Nurses jobs have become about the task and the paperwork , with fewer nurses looking after more patients. And whilst there are still some who manage to make time to connect with those in their care, there are many more who are on a treadmill running from task to task.  Many of these nurses are then given students to look after and they do their best to make it a great experience in difficult circumstances. That rushing and being task focused doesn’t do the best job of mentoring and teaching and doesn’t support the best possible care which otherwise might be achieved. Perhaps if the health care system had more nurses and less management you would see a lot more friendly nurses.’

How do we as a collective ponder and plan for change to improve not only the outcomes of what we’re trying to achieve as nurses, but provide a much more enjoyable workplace for all those in it? Remembering that in residential care, the workplace of nurses and care-giving staff is also the home of residents needing support.

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Dysphagia Diets – Are we all understanding each other?

Dysphagia diets and a lack of understanding of how to implement them consistently, is increasing risk to residents in aged residential care services.

Texture modified diets are commonly used in aged care facilities to manage the risk of aspiration pneumonia and choking with eating and drinking.  Residents with dysphagia may be placed on a texture modified diet following assessment with a speech and language therapist.  However there are often a range of terms used for texture modified diets, and differing opinions on exactly how the diets should be prepared.

Confusion with terms, and the types of foods and fluids offered leads to increased risk of harm for the resident.  This is particularly obvious when transferring from one facility to another.  Information on texture modified diets is passed to the new facility who may use different terms.  For example a site may report ‘this resident requires a soft diet’ and the interpretation of this diet at the new facility is to puree all food.

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a framework to standardise terminology and offer simple testing methods to check that the preparation of the diets are correct. Dietitians New Zealand and Speech Language Therapists of New Zealand have endorsed in principle the IDDSI framework.

The goal is to reduce the risk of harm for our patients and residents due to miscommunication and poorly prepared texture modified diets.  It is important to note that the framework relates to dysphagia diets only.  Residents may be on a modified diet due to other factors not related to dysphagia.  For example a resident with no teeth may need softer foods but can actually manage sandwiches.

The good news is that for many sites, there is very little change needed as they are already using the correct terms.  The diagram above shows the new terminology and the minimal change in wording;

  • ‘Smooth puree’ becomes pureed (which is also extremely thick fluids)
  • ‘Minced and moist’ remains unchanged
  • ‘Soft diet’ becomes ‘soft & bite sized’
  • Moderately thick and mildly thick remain unchanged for thickened fluids

The IDDSI framework assigns standard colours and numbers to assist with easily identifying texture modified foods and fluids.  Some manufactures of texture modified foods and fluids are looking at ways to incorporate the terms, colours and numbers onto their food packaging.

Food and Fluid Preparation and Testing

The IDDSI framework offers simple tests to check that the thickness of the fluids or the size of the particles for modified foods are correct.  The tests use forks, spoons, fingers or syringes – equipment that is readily available at sites.

With training and education on how to do these tests, kitchen staff and managers will be able to easily check their texture modified diets and thickened fluids are prepared correctly.

IDDSI App and Website

The IDDSI framework have developed many resources and videos to assist with the standardisation process.

Download the app https://play.google.com/store/apps/details?id=com.appdataroom.iddsi&hl=en

or go to www.IDDSI.org

or ask your dietitian and speech language therapist for more information.

Where to From Here?

Here are some small steps to help implement the IDDSI framework at your site:

  1. Stop using any terms that are not on the framework. The term ‘mouli’ is not recognised and should not be used to describe a texture modified diet.
  2. Download the app or look at the IDDSI website to familiarise yourself with the framework.
  3. Try testing one of the textures you currently prepare. Does the ‘puree diet’ your site produce pass the spoon tilt test?  Does the size of the minced food for ‘minced & moist diets’ fit between the prongs of a fork?  Is the size of meat offered for residents on the ‘soft & bite size diet’ the size of your thumb nail?
  4. Ask your dietitian or SLT for further training on the correct testing and preparation of dysphagia diets.

This article was contributed by Liz Beaglehole NZRD (Canterbury Dietitians) and Anna Miles PhD, Speech-language Therapist, Senior Lecturer, Speech Science, School of Psychology. The University of Auckland.

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Medication Management Audit Tips

 

Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents are (first two are key for residential care):

Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments.  Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished.  Below are common errors which continue to be made:

Aspect of medication management Common Errors 
Medication chartsNot datedNot signed by the prescriberNot signed by the General Practitioner or Nurse Practitioner at each review (3 monthly)Not legibleAllergies not documented (or inconsistent with other resident documents)Transcribing on medication charts or PRN signing sheetsPRN medication charting does not include ‘indication for use’Medication order does not include time, dose, frequency, route, type etc
Signing sheetsMissed signatures on the signing sheetsOnly one signature (instead of two) on controlled drug administration records and registerPRN medication not signed for accurately
Self-medicating residentsCompetency to verify self-medication not signed by prescriberCompetency for self-medication not signed as having been reviewed by prescriber (3 monthly)Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order)Not retaining a current list of all medication ordered for self-medicating residents
StorageMedication not securely stored (also see ARRC D15.3(c) Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy)Controlled drugs not stored in locked cabinet in locked roomDrug trolley left in common areas unlockedExpired medication continue to be stored on site (should be returned to pharmacy)Medication for resident who has been discharge or deceased remain on siteMedication fridge temperature not monitored / recordedLabels on medication containers not clear / legible
Identification of residentPhotograph not representative of current presentation of resident (photograph should be colour)Photograph of residents not validated regularly
Medication errorsNot reportedNot managed (through an adverse event management process to ensure identification of contributing factor and preventive measures).
CompetencyAll staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competencyAnnual review of medication competencies

If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor.  The risk is too high for the residents and your organisation.  Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.

Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty.  Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering.  Refer to the Aged Related Residential Care Contract (ARRC) for further information.

Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.

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