Models of care and addressing Isolation

Since the emergence of residential care facilities in New Zealand, the models of care have continued to change, but are they changing fast enough? The clinical needs of residents have escalated and so the way services are provided must also reflect a change in practice to meet changing resident needs. A common theme being reported among older member of our communities is that of isolation and depression. Isolation, according to the Collins dictionary relates to separation, withdrawal, loneliness and segregation.

I was fortunate to visit Greece recently which is reputed to have a larger proportion of older adults than most other EU countries.  Gerontology is derived from the Greek words geron, “old man” and -logia, “study of” so it made sense to discuss models of care with families and health care professionals including pharmacists.  I discovered there are few residential care services in Greece and those that do exist are found mostly in Athens rather than the islands. Families provide the majority of care with ‘family’ being noted as the key foundation to Greek society. Grandparents are frequently living within the extended family with the younger generations and taking responsibility for caring for their grandchildren.  The economy is poor and social networks are heavily relied on to provide support.

From my observations, conversations with others, and literature, the older adults of Greece are kept actively engaged in the community. They are frequently involved in running family businesses if they are not relied on for supporting the needs of their children or grandchildren. Family networks remain strong and when interviewing people about how older adults will be cared for, the automatic assumption is that family will provide that service. Dr Elizabeth Mestheneos told me that approximately 1% of their older population may well be in residential homes. There are Open Care Community centres in virtually every Local Authority which are called KAPI. There are also Help at Home services and Day care centres in some Local authorities.

The models of care and workforce capacity currently in place in New Zealand are unlikely to meet increasing demands so change is needed.  The aged care sector could lead change as new models are developed, trialed and advanced.  Multiple studies confirm these new models need to include holistic, consumer directed services.  Not only meeting physical needs but also social connections and the opportunity to be involved in meaningful activities that contribute to others. This also includes some use of technology to support connections with others. While they are of assistance to some, there is no substitute for human connection, person to person, face to face. The experience of ageing, social network supports, funding models and the context in which care and support are provided certainly differ from country to country.

In New Zealand residential care settings we have activities / recreational programmes which support inclusion and engagement.   Being involved in meaningful activities are also key factors in contributing to a sense of well-being. I observed older adults in Greece undertaking meaningful activities in the community like feeding the communal cats of Kos or looking after grandchildren, continuing to run a second hand open-air shop to add to the family income or playing games with friends games. Groups of older men often congregated outside cafes for conversation, coffee and playing cards or board games.  A Menzshed story reflects on how one New Zealand community are attempting to address the gap ageing can create in the life of some men. While funding is different in NZ to Greece and the family network is more often scattered geographically in New Zealand, there remains more opportunity to include community. The care setting could also be enhanced more by reflecting the smaller numbers of people we are used to living with in the family home, rather than the larger numbers in some care facilities. A model that more closely reflects the life patterns our community members have been used to, with them directing how these continue into the latter years of life with the goal of ageing in a healthy way, optimising body, brain and social networks.

 

 

 

Mattresses – are your mattresses causing harm?

Mattresses aren’t just something to lie on but if not maintained and cared for appropriately, also have the potential for causing harm.

As I travel a lot for work, I have the opportunity to test many different mattresses, all with varying degrees of comfort.  This reminds me how difficult it must be for those who may be suffering painful joints to get a good night’s sleep.  Appropriate mattresses are not only required to reduce pain from positioning discomfort but also reducing risk to residents. This include ensuring the mattresses are of a suitable standard and fit for purpose.

I’ve seen a number of mattresses which had hardened and torn linings and were well past being able to provide much comfort or an appropriate degree of pressure support. Some had masking tape used in an attempt to cover splits in the mattress cover.  Others had holes in and were badly stained from exposure to body substances.  As the residents in care are becoming frailer, with increasing acuity, the need for ensuring appropriate pressure support is crucial to preventing pressure injuries, maintaining comfort and maximizing the opportunity for good sleep.

There is the potential for old and in poor condition mattresses to be a potential source for infection transmission.  For those of you operating newer facilities, this may not yet be an issue. For older facilities, part of stock and resource control should include mattress stock checks to verify they are in fact still fit for use.  When conducting checks, determine the mix of mattress types you have and speak with your supplier about a replacement programme should this be necessary.  As mattresses differ, so do beds and it’s important to make sure the mattress you use is appropriate for the particular bed type and size.

When reviewing your mattress stocks and purchasing new mattresses you might like to think about the following factors:

  • Only purchase from reputable suppliers. Review the manufacturer’s instructions for use to ensure they include verification of cleaning instructions and ask about preventative maintenance. This may include staffing training e.g. via the use of online training videos or instruction booklets.
  • Make sure you record the date of purchase and do your best to track each mattress and pillow to maximize warranties and make plans for replacement. Add the item to the facility cleaning schedules for regular cleaning and drying of exterior surfaces which should be durable, water-repellent and quick drying. They should also be seamless, if possible. When there are seams or edges, much sure these are situated away from resident skin contact to prevent absorption of liquid into interior and increased friction.
  • All seams must be tightly closed and sealed. Masking or packaging tape is not appropriate for sealing. When mattresses become worn and tear, you might like to have a supplier representative review to see what options are available for repair or replacement.
  • When reviewing the condition of mattresses, inspect all mattress surfaces, covers, seams and zippers for proper function and damage including wear, tears, splits, cracks, punctures, permanent odours and stains. If visible contamination from body substances are present, determine appropriate steps (eg. replacement or repair).
  • To support longevity of mattresses, remind staff not to place any furniture or sharp objects on mattresses. Protect the mattress with mattress protectors only if advised by the supplier this is appropriate. A number of pressure support functions in mattresses may be adversely impacted by the use of additional mattress coverings to do check.
  • Cleaning and disinfection must be considered in relation to mattresses, covers, wedges, cushions and pillows which are all classified as non-critical medical devices. Clean and low-level disinfect according to the manufacturer’s instructions between different resident use and when visibly soiled. Some mattress covers are removable for laundering so remember to verify which ones can be cleaned separately.
  • Remove damaged or stained items from service and report these in your maintenance book or to the Manager. Follow manufacturer’s instructions for use and disposal of damaged mattresses, covers, and pillows, and in accordance with infection prevention and control guidelines.
  • Ensure when using alternating therapy type mattresses that there is a process in place for a shift by shift verification that the pressure is maintained at the current level for the individual resident utilizing that mattress. If you plan to use an air alternating topper pad on a mattress, ensure it’s suitable for the mattress as depending on heights and size, it may not be appropriate.

Harm prevention can also be supported with advances in technology such as Pressure Monitoring sensing devices to ensure appropriate pressure distribution.  I’m not aware of anyone who can rent or lease out Pressure Mappers in NZ. However Cubro have one that they can bring onsite to facilities for training and education. Make contact with your supplier to see if they can assist if this could be useful for you.

Also remember that other devices used in beds should be checked  as well to ensure they are still safe and appropriate for use eg; wedges, rolls, pillows, seat cushions, mattress covers (where these are appropriate for use), bed sensor monitoring pads.  For reading on how to choose the best mattress option for your needs go here.

For more related information view here.

Article compiled by Gillian Robinson (RN, BN, Lead Auditor) for Healthcare Compliance Solutions Ltd.

Leadership of your team

 

Empathy and perspective are two concepts well known Leadership author Simon Sinek speaks about in relation to leaders. He talks about the real job of a leader as not being in-charge but taking care of those in our charge.  How many leaders play the blame and shame game when things don’t go as planned?  Instead how would it be if leaders in aged care services worked in accordance with a Leader’s Oath.  My version is noted below as an example.

You may want to create your own for your organisation, or adopt this.

The Leader’s Oath

I focus on the betterment of this organisation above my own career needs

I  focus on accountability above the need to be popular

I focus on caring for those in my charge over being in charge

I focus on clarity above certainty

I share clear expectations

I hold myself accountable for all employees poor performance including my own

I welcome respectful challenges

I will table the tough issues

I treat all interactions as though my career depends on a successful outcome

I am committed to personal and professional development

I am focused on excellence.

 

While the above Leadership Oath forms a focus for clinical leadership, it’s necessary to make sure your nurses are familiar with the ARRC funding agreement responsibilities for Registered Nurses. These are also clearly defined in the HCSL policies and procedures to ensure they’re integrated into practice.  The ARRC includes time-frames for nursing documentation responsibilities, while the nursing council guidelines for delegation define staff delegation of staff working under the supervision of Registered Nurses are appropriate led and supported. When we refer to tabling the touch issues, one key aspect of leadership is holding staff accountable.  Nurses are often not keen to hold others responsible for their conduct and performance and therefore avoid performance managing staff when performance is below the expected standard.  This in turn means the service provided will be below the expected standard.  If you want to provide the best care and support to those in your care, these are skills you must learn and put into daily practice. To learn more about these skills and others needed for leading a team of care and support staff, go here.

Critical thinking – the foundation of good nursing practice

There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.

It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff.  To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential.  The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.

Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care.  The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario.  Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.

There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.

Click here to read more on critical thinking.

 

 

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 compliance

gaps

Missed 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 assessments

including InterRai

Not 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 risk

Assessment 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 notes

Not 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 Term

Care Plans

Not 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 Term

Care 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 Plan

Evaluations

Review 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-Disciplinary

Input

Lack 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 and

procedures

Not 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.

 

ANZAC day commemoration

On the 25th April each year we remember those who went before us to fight for the protection of others.  While emphasis is often on those who died in service to their country, it’s also a time to remember those who returned from war changed and altered forever by the experiences they’ve had.  Not just for the soldiers going and returning to war but their family.

The mother who describes holding her son as he heads off to the front line. Embracing him, breathing in his smell which a mother knows so well.  Holding her head against his chest hearing the beat of his heart wondering if she’ll ever be able to hold him and hear his heart beat again.  Feeling the harshness of the fabric of his uniform and wondering what other harshness he’ll encounter.

The soldier as a member of a family, not only left grieving mothers behind but were sometimes already parents themselves going off to war leaving wives and children behind.  All family members impacted in their own way from their own perspective of events.  How does a wife or child accept the decision of the men in their life going to war, to do ones duty leaving children wondering why they were being deserted in favour of the uncertainty of battle? Those children then growing older day by day until the time they themselves are in their 80’s and find themselves still welling up in tears at the memory of the day their father left to go to battle. Not understanding but seeing the change in the father who returns, different, distant and ill from the effects of sand breathed into his lungs while stationed in Egypt.  The soldier returning, having nightmares of horrors seen which cannot be unseen or forgotten. Limbs and body intact but emotional scars and ongoing adverse health issues.  Not all wounds are visible.  Those who were victims of war yet no memorial bears their name.

I visited the Gallipoli exhibit at the Museum of New Zealand ‘Te Papa’ (our place) in Wellington last November with my mother and sister.  I was mesmerized and deeply affected by the raw emotion depicted in the models created for the exhibit by Weta Workshop. The image of this nurse, Staff Nurse Lottie Le Gallais who was on board the hospital ship Maheno which set out from Wellington. She’d hoped to catch up with her brother but the model shows the anguish of the moment she receives her returned letters to him saying “killed, return to sender”.  I can’t imagine the strength needed to sustain such pain amidst the anguish of war but still carry on to serve those needing care.

A time to ponder on the Anzac values of courage, compassion, commitment and comradeship and see if they are reflected in our own organisations as relevant to care services. This Wednesday, 25th April, Anzac day is a time to reflect and be grateful – lest we forget.

 

 

 

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?

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.

Diabetic diets – clinically appropriate in aged care or not?

When balancing the clinical needs, requests and preferences of each resident in-conjunction with their right to choose, a number of factors need to be taken into consideration.  We all recognise that theory and practice can change over time so when I asked Liz Beaglehole (Registered Dietitian) her professional view on this topic is, she offered the following:

 

The recommendation for older adults with diabetes in aged care facilities with stable diabetes is to provide an unrestrictive diet as much as possible. The notion of a ‘diabetic diet’ is outdated due to the increased risk of hypos and unwanted weight loss.

 

This is very individual however, a frail 80 year old woman with diabetes will likely have no diet restrictions however an obese 70 year old who may be otherwise stable would benefit from a more restrictive diet.  Advice from a dietitian for individuals is recommended.

 

Overall, guidance from the resident about their wants is probably what determines the diet provided. This may be in accordance with recommendations or not.

 

Generally, the medications should be fitted to the usual eating pattern of the resident.  In aged care facilities there are regular meals and generally balanced carbohydrates over the main meals (assuming good food intake) so usually this is fine.  If someone has a reduced food intake, and is on insulin then a unrestrictive diet would be best.

 

For my menu planning I tend not to plan any special diabetic options on the cycle menus.  I may include a low fat / low sugar dessert option if sites request, but generally my philosophy for aged care is not to restrict foods!

 

Liz is involved with a PEN (practiced based evidence in nutrition) review of the question ‘Do institutionalized, older adults (65 years of age or older) who closely follow a diet prescription have better control of their chronic disease (e.g. diabetes) than those who do not?‘ This is due by the end of March so further practice updates from this review may be available then.  Liz noted that generally the evidence suggests there are no benefits with a prescriptive diet vs a more liberal one.

This article was kindly contributed by Liz Beaglehole NZRD (Canterbury Dietitians).

Food Control Plan registration update

Those of you who are members of the New Zealand Aged Care Association (NZACA) may be aware that we (Healthcare Compliance Solutions Ltd) have been contracted by the NZACA to develop what is known as an Industry Body Customised Food Control Plan (FCP). This is to be approved by the Ministry of Primary Industries (MPI) and made available to all NZACA membersThis customised plan comes under section 40 of the Food Safety Act and has been developed with the intention of streamlining audit process for Age Related Residential Care providers to use. There is an extended date for registering under this plan. 31st March was the date noted for registration however for this process, the date for completion of the registration process for use of the Industry Body NZACA FCP will be 31st May 2018. 

 

Instead of registering with the local Council, those members who are taking advantage of the national customised food control plan will register directly with Ministry of Primary Industries.  What is being worked towards currently is for this plan then to be audited by your Certification Designation Auditor Agency auditors in conjunction with your other audits. It is our understanding that the deadline for registering with MPI has changed to take the Food Control Plan approval into consideration so please check with NZACA to verify when you need to have your registration completed by.

 

How far have things progressed currently?  We have submitted the draft of the customised plan to MPI for approval.  The content of this plan goes beyond the standard Food Control Plan as it will need to also meet Certification and ARRC funding agreement audit criteria. This is designed to be an all in one set of documents so that as noted, it assists with the streamlining of audit.  We understand this approval process could take 4 – 6 weeks with a period of refinement if necessary and finalising of the documentation to follow, before a Gazette notice would be published.  This notice is necessary to proceed with association members using the Industry Body customised FCP as part of their other certification audit processes.

 

A huge thank you to Liz Beaglehole (Registered Dietitian) from Canterbury Dietitians who assisted at short notice with the reviewing of documentation contents which form part of the FCP.

 

There is work to be completed behind the scenes in an attempt to align audit time-frames which are not the same for all providers so while the intent is clear, the reality of achieving what we are setting out to do, is yet to be confirmed.

 

We support the work of the NZACA and were very pleased to be able to support the age care sector in this way.  We undertake to do what we can to support this process to a successful outcome.  NZACA will be updating their members as we work through this process.  If you are not a member, this may be a good time to join to take advantage of just one of the benefits they offer to support their members.

If you would like further support with the implementation of your Food Control Plan, please feel free to contact us.

Moving  and Handling People – Good Practice Guidelines – December 2017

The Draft Moving and Handling guidelines are currently being finalised with the view to be implemented from December 2017.  Developed by Worksafe, they cover Health and Safety at Work Act 2015 (HSWA) duties and risk management for PCBUs in the health care industry and supersede the 2012 guidelines.  There are a range of factors noted in these which need to be taken into consideration for those building new facilities or doing refurbishment of existing facilities. There is also a raft of information on Bariatric Care which is an increasing part of the services being provided in residential care.

The draft guidelines include the following:

Please note that there is not a complete consensus on the criteria for classifying a person as bariatric based on weight or Body Mass Index (BMI). However some examples include those people:

– with a body weight greater than 140 kilograms.

– with a BMI greater than 40 (severely obese), or a BMI greater than 35 (obese) with co‑morbidities.

– with restricted mobility, or is immobile, owing to their size in terms of height and girth.

– whose weight exceeds, or appears to exceed, the identified safe working loads (SWLs).

Health risks for bariatric clients

People who have been bariatric for a considerable time face chronic and serious health conditions, many of which should be considered before moving or handling them. Health conditions to take into account include:

– skin excoriation

– rashes or ulcers in the deep tissue folds of the perineum, breast, legs and abdominal areas

– fungal infection

– bodily congestion, including causing the leaking of fluid from pores throughout the body, a state called diaphoresis, which makes the skin even more vulnerable to infections and tearing

– diabetes

– respiratory problems

– added stress to the joints, which may result in osteoarthritis.

Planning for bariatric clients:

The planning process for bariatric clients in order to reduce moving and handling risks should include:

– admission planning

– client assessment

– communication

– room preparation

– mobilisation plan

– equipment needs

– space and facility design considerations

– planning for discharge.

Facility and equipment needs for bariatric clients

Health care and other facilities providing care for bariatric clients need to provide adequate spaces for these clients. Some considerations could include:

– ramps and handrails at entrances

– bariatric wheelchairs

– that the facility’s main entrance has sufficient clearance

– adequate door clearance and weight capacity in lifts

It must be remembered that the above comes from a draft but as drafts often end up being very close to the finished document, I felt it timely to share this information. To read more on Health and Safety in the Workplace go here