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ROYAL COMMISSION: No time, no extra staff and little diversional therapy

Day 6 into the third series of the Royal Commission into Aged Care Quality and Safety involved another panel full of aged care workers from the sector talking about the need for staffing ratios, lack of time to provide good care, better encouragement for education around dementia, and the inclusion of diversional therapy in aged care facilities.

Ms Maggie Bain, retired Diversional Therapist, said many people don't know about the benefits of Diversional Therapy or how much it alleviates stress for staff. [Source: Aged Care Royal Commission].
Ms Maggie Bain, retired Diversional Therapist, said many people don't know about the benefits of Diversional Therapy or how much it alleviates stress for staff. [Source: Aged Care Royal Commission].

The aged care professionals panel consisted of Assistant-In-Nursing (AIN) staff, Susan Walton and Suzanne Wilson; a retired Diversional Therapist (DT), Maggie Bain; and a current Registered Nurse (RN), who was only referred to as Elizabeth throughout the entire proceedings.

Each panel member gave insight into their daily work routines, which involved inadequate staffing, no time to provide good care to multiple people, especially people with dementia; education not being a priority for staff, and an obvious gap between people who manage money in facilities and the people who deliver care.

The panellists also expressed disgust and horror at the recent case studies that have been presented to the Royal Commission throughout the third hearings in Sydney around residents with dementia.

At the end of the panel hearing, Commissioner Richard Tracey AM RFD QC, thanked the panel for their constructive feedback around dementia and what work is like for aged care staff.

Diversional therapy could take pressure off staff

The work of DT Maggie Bain, became a talking point on the panel, as many aged care staff don’t know what the role does and how it helped people with dementia.

Counsel Assisting Mr Paul Bolster mentioned the Royal Commission so far has not heard from a Diversional Therapist.

Some of the panellists had not heard of Ms Bain’s role before, suggesting their workplace only had “activity officers” to keep residents with dementia entertained.

Ms Bain explained her role as being important to enable people with dementia while taking the pressure off aged care staff.

“The main purpose is to provide and help a person with dementia to participate and to thrive as best we can and to enable them through activities. Activities can be anything from a hand massage to walking,” says Ms Bain.

“It skills people up. Even though a person has dementia, they still have a personality and they still are a person… We get to know their story, we work very much to that person as an individual, in a group or one-on-one.

“We really just work for the best outcome for the resident or person.... Management don’t want to know about [us]. They don’t understand the need for people with dementia needing the space to walk and be themselves really.”

People with dementia are known to engage in “sundowning”, where people see the end of the day and want to return home to a cooked meal, but don’t know where to go, resulting in elderly people with dementia wandering around facilities.

“People do walk, they just want to find where they belong,” says Ms Bain.

AIN, Ms Suzanne Wilson said her workplace trialled activity officers in the afternoon which worked really well, however the practice, eventually faded out and returned to normal.

Staff work overtime due to long handovers between shifts

AIN, Susan Walton explained that she had to go to work 30-45 minutes early for handover because the RN took time handing over to the new shift.

She believes the main problem was the lack of people available to help with all of the work.

At any given time, Ms Walton found herself taking care of 40 residents around two wings, with an RN moving between different levels of the facility.

It was important for Ms Walton to have a proper handover since 90 percent of the people she cares for have dementia.

Panellist Elizabeth says, “Handover is your bread and butter, if you don’t know what is going on you miss care… You need to know if there are any changes in people's behaviour.

“If you don’t get a proper handover, you are working blind.”

DT, Ms Bain, agrees the handover is an important process in aged care, and has had many experiences where she didn’t have time to read a handover.

Management don’t support education

Ms Wilson has been working in a dementia-specific unit for five years and had to take cost and effort on to her own back, without support from her workplace, in getting further education in dementia.

She completed a Degree in Dementia at the University of Tasmania, which she found incredibly helpful to her work.

Her workplace, however, has not used the skills that she learned from the course or been asked for her opinions, knowledge or assistance around dementia.

There are training days at her aged care facility, but they have to be undertaken during work if they have the time.

Ms Wilson said most of the time the staff can’t do it during working hours and have to do the training after work and without pay.

Ms Walton had a similar experience at her current workplace and said face-to-face training has stopped, replaced by computer training programs instead.

“Most staff members are not trained across all areas. You need specialised training for all staff,” says Ms Walton.

Does mixing residents and residents with dementia work?

The panel had differing opinions around having residents and residents with dementia together in the same house or facility.

Ms Bain was all for having residents together, saying it works extremely well.

“It helps people with dementia to be social, to be around people, to experience the things that other people experience like a walk in the garden or music concert,” says Ms Bain.

Ms Walton had differing opinions, admitting that the dementia patients can get violent with people that don’t have the condition.

RN Elizabeth said it’s hard to draw a line between it, since it can work, however, people can take advantage of someone with cognitive difficulties.

She gave an example of a dementia resident who struggled to communicate and would wander. She wandered into a person’s room who didn’t have dementia and was sexually assaulted by that person.

Elizabeth believes it does leave people with dementia open to vulnerability if they are mixed with people who don’t have dementia. She said it comes down to management deciding where people are placed in facilities.

No time to provide good care

All panellists explained instances of being run off their feet, unable to attend to all residents that needed help, stemming from poor staffing ratios.

The fourth case study heard by the Royal Commission focussed on a woman who had pressure sores and needed to be turned every four hours, along with a host of other instances of poor care.

Elizabeth was adamant in her assertion that pressure sores are a signifier of bad care in an aged care facility.

“If they were turned every four, if that, it's not surprising they have a pressure area, it says the care wasn’t good enough and not enough staff,” says Elizabeth.

“[There needs to be] mandatory reporting for pressure areas. It means your nursing is not good enough… If there is a pressure area, the system is failing.”

Ms Walton mentioned air mattresses would benefit people with pressure sores, however, requests for air mattresses went unfilled often.

“Familiarity with residents is important for staff to identify and assessment when a resident is exhibited odd behaviour,” says Ms Wilson.

However, her facility doesn’t require her to access residents for issues. Ms Wilson says it was always an automatic thing that all aged care staff do.

Personal items or nostalgia eases residents with dementia

Residents with dementia need to be calmed before resorting to restraints, which can make matters worse rather than address the problems.

Ms Bain outlines that most behavioural challenges from people have been caused by not know people.

She says many staff are completely run off their feet and don’t have time to connect with residents.

In most cases, wandering dementia patients are just looking for something familiar to comfort them, says Ms Bain.

“Memories from the past is important for a person with dementia.”

Things like pet therapy, child representation therapy, nostalgia, and community engagement has improved behavioural issues from dementia patients.

Physical and chemical restraints

Topics like physical and chemical restraints were difficult to answer, but all panellists believe there are better ways to help a person with challenging behaviour rather than using restraints.

Ms Walton said chemical restraints were commonly used considering staff don’t have time to deal with residents who have difficult behaviour.

In many cases, Ms Walton and Ms Wilson weren’t aware of what psychotropics do or what bad effects it might have on the resident. Both AIN’s don’t administer drugs in any way.

The AIN’s facilities have rolled back physical and chemical restraint use, however, they sometimes do occur in extreme cases.

Elizabeth was mortified by previous case studies heard at the hearing of excessive physical and chemical restraints used on residents and hopes these practices will change after the Royal Commission.

Mandatory ratios needed

Panellists unanimously agreed that mandatory ratio laws need to be put in place, similar to childcare which is currently four-to-one.

Elizabeth says, “You need to have eyes on the patient every day. What you are doing in that interaction is accessing them physically and cognitively. The ratios aren’t there, you can’t have eyes on the residents.

“You are prevented from your basic care. You can have a person change in a heartbeat if they get a UTI and have delirium.”

Elizabeth added the Nurses Union had undertaken research into ratios and found 30 percent should be RNs, 20 percent Enrolled Nurses (EN) and 50 percent AINs.

She believes this ratio would stop or minimise violence among residents with dementia and allow better care to all residents.

Ms Walton says, “You cannot treat people like [this], [staff] need more support, you need ratios in care. One person to 40 residents, you can’t do it.”

Best care for dementia patients

The conclusion of the panel resulted in calls for education put first, mandatory ratios and more empathy in aged care facilities.

In Ms Bain’s statement to the Royal Commission, she said, “Good dementia care feels like a living, breathing, great attitude held by all management and staff.”

Ms Bain added that the sector needs room for a new type of dementia care for early onset dementia patients since there is currently no place for people with early onset dementia.

She believes any training and education around dementia and palliative care would be a great help to staff.

Ms Wilson wants mandatory ratio laws, along with registration of aged care workers to weed out staff that don’t want to be working in the industry and are working there out of obligation.

Elizabeth raised concern briefly over the homeless population, with many elderly individuals in that situation due to mental decline.

She wishes for there to be more help with elderly homeless people, saying health care should be accessed on a needs basis, rather than an age basis.

Additionally, Elizabeth said reporting of pressure areas should be mandatory to target homes. She believes pressure areas are a proxy for poor aged care.

Mr Walton indicated ratios being important, as well as accountability for those who receive money for aged care. She doesn’t believe funding is going to people who need it.

The hearings will recommence on Thursday, May 16.

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