Case Studies in Aged Care

Changing Practice in Aged Care

Changing practice in age care is a case study that outlines one approach to working with staff in an aged care facility that resulted in approved knowledge of several aspects of care and the documentation of that care.

We've all heard this statement, "If it's not documented, it didn't happen." Poor reporting and a lack of communication have featured prominently in the Royal Commission's hearings, highlighting the importance of up-to-date record-keeping. Not only for the provision of quality care but to also avoid any legal implications. Good resident documentation is essential. It is evidence of the provision of the care and support that we provide. Well-written care and support plans, assessments, and reviews, accompanied by detailed resident-centred progress notes demonstrate quality of care that is tailored for each individual. Many residential age care facilities that provide good quality care, do not perform well in accreditation assessments as their documentation of that care does not reflect the individual assessment and care given.

Such was the case with this facility. This facility was 130 beds in a regional area. It had approximately a hundred staff with the majority of these naturally being personal carers. Whilst I'm often employed to conduct a needs analysis, in this instance, the facility management had identified training needs based on audits of the documentation of care. They identified that staff required up skilling in recognising clinical deterioration, assessment, care planning, and evaluation, advanced care, resident-of-the-day, and medication incidents. Together we agreed that writing progress note training should also be included as evidence of a care is essential.

An action plan was developed in consultation with management. The facility was experiencing some staffing shortages, so it wasn't possible to get staff to come into a training session of an hour or two. So we agreed that staff would be trained on shift during work hours in 101 or small groups. To that end, we agreed that the sessions would be contained to 10 to 15 minutes and would be delivered between episodes of resident care. We also chatted about combining assessment, care planning, and evaluation, and the advanced care as part of the resident-of-the-day process. We determined that the basis of the training would be the facility policies and procedures. And we used the documentation and their forms. Training sessions were conducted over several days, over a period of two and a half weeks. It was done on all shifts. Staff were also mentored one-on-one post-training when they were completing documentation of forms and progress notes. And this reinforced the training.

Many training sessions evaluated on participant attendance only. My philosophy is that training needs to translate into practice and outcomes. Not just impact on the learner about their perceived change in knowledge or confidence. The evaluation strategy used for this case was based on Kirkpatrick's Evaluation Model. The evaluation measures included staff participation in numbers, and staff satisfaction of the training sessions, staff self-assessment of learning, pre-and-post spot checks, and audits of training documentation, including progress note writing, and completion of relevant forms. Pre-and-post audit of resident-of-the-days and medication incidents and medication charts.

During the two and a half week period, most of the staff were trained. Staff feedback about the training was sought. And as this graph shows that staff felt that the content of the sessions was informative and useful. They felt that the information was presented clearly, that it was useful for their daily work, and the way that the content was presented to them was effective. This graph shows that the staff self-assessment of their learning shows that their knowledge, understanding, and skills related to the training topics increased after the sessions and they rated the topics more important as well.

Transition to practice was evaluated by the accuracy of the documentation and adherence to procedures about care and reporting. Pre-and-post training audits were conducted by the facilities quality coordinator and myself. Pre-audits covered the three week prior to training and the post-audits occurred two weeks after the training. The documentation of forms and progress notes related to clinical deterioration improved by 5% after the training. The use of documentation models such as SBAR in the writing notes increased by 58% post-training. The pre-audit of the resident-of-the-day showed that there was a lack of detail in the documentation in the resident-of-the-day, to show that the assessment medication progress notes and other charts had been reviewed. It also showed that there wasn't a lot of engagement with the residents or the representatives in the resident-of-the-day process.

The post-audit trends revealed an increase in resident engagement, personalised documentation, and the adoption of the use of SBAR for the documentation of the resident-of-the days. Post-training there was a 64% increase in reporting of medication incidents. Most of these were from residents declining to take their medications. This resulted in a review of the medication charts by GPs and an overall reduction of medications that the residents were prescribed.

Working in partnership with management we developed a workable and effective approach to staff training. The training was tailored for staff and delivered while they worked on shift. The materials and their presentation were applicable to their daily practice and learning was reinforced by the mentoring of staff whilst they completed resident-of-the-day progress note writing and completion of forms. Whilst it is important that the staff enjoyed this training and felt that they learned, it is essential that the training translated into changes in practice. This was assessed by audit and using continuous improvement approach, feedback was provided to individual staff on areas for their improvement. Management were also provided with a comprehensive report that contained recommendations for embedding change to sustain these new practices. It's pleasing to note that subsequent follow up with his facility several months later, they report that the changes in practice have been sustained.

I trust that this case study resonated with you, and I look forward to hearing from you about how I can work with you to help your staff improve their performance and improve the quality of care and their documentation in your facility.