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.   

I visited the Gallipoli exhibit at the Museum of New Zealand ‘Te Papa’ (our place) in Wellington 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.

I live in Christchurch and after the recent terrorist attack resulting in the death of 50 people, we’re seeing and feeling the result of war-like destruction of life. You see it in the faces of those closely affected. The internal pain of senseless loss.

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 Thursday, 25th April, Anzac day is a time to reflect and be grateful – lest we forget.

 

 

 

Culture Change in Long Term Care

Culture is a word we hear a lot and goes hand in hand with the concept of culture change.  In this article I’d like to touch on how to facilitate culture change and why it is beneficial to your long term care setting.  Let’s face it, aged residential care in New Zealand is changing rapidly and this impacts the experience of residents, staff and visitors to long term care settings. It impacts their desire to be in your care facility or to move somewhere else. This applies to be both residents and staff.  Families often choose the care provider for their elderly relatives.  What do they perceive when they visit you?

There are also barriers and challenges to creating and sustaining a definable and deliberate culture. The experience of the residents and staff is a result of the culture (behaviours) which should be aligned to your organisation values, mission and goals.  There are well publicised workforce shortages and high turnover of staff. Long term care is also in the middle of change from paper-based systems to electronic storage and management of information. The environment in which care is being provided is also changing through new construction of buildings from a institution to non-institutional. The atmosphere being created by those within the long term aged care residential setting is changing to a more relaxed feel.

Nursing care  and direct support is now also being provided within retirement village studios, apartments, villas, homes.  This means a change of not only the context of care.  Ensuring person centred care where each individual feels seen, heard and respected takes consistent focus and strong leadership.  Not always easy in a industry that is changing in so many ways. I wrote in a previous article on workplace culture that behaviours could be a better point of focus rather than simply focusing conversation on culture as a concept.

The behaviours which support a culture you can be proud of and one that sets you as an industry leader, require a long term focus and not just a one time exercise.  The strong leadership needed along with education and ongoing communication is key to setting a desirable culture.  Have you aligned your staff, management and Governance behaviours with your organisation vision and mission statements?  Behaviours reflect actions and they can be optimal actions, good actions, poor actions or non-action.  All will have an outcome which impacts the residents experience and determine how they feel about residing in your long term aged residential care setting.

For change to occur there needs to be a focus on improvement, a reason to change which residents and their families see as beneficial.  We tend to stick to doing what we’ve always done unless we can see a personal gain or something which provides a sense of satisfaction on a personal level.  What’s in it for me?  Culture change is not something that’s going to be achieved from a top-down approach. It’s going to take engagement from all levels of the organisation and create wins for those involved. Without perceived gains or wins, people stay stuck in old habits which don’t fit the new expectations of those seeking care and support.

If you’re the manager or CEO and delegate a ‘change management’ process to someone else, then expect to check in later to find wonderful results without your direct involvement and engagement, you may be disappointed.  Culture change is a team effort. To achieve change, everyone needs to participate.  They need to believe in the outcomes you’re trying to achieve with whatever strategies or initiatives you put in place.

Who is going to lead change?  There is an old saying that everything flows from the top down and this is also true of culture.  If the Board are dysfunctional then there should be no surprise when staff working at all levels of the organisation are dysfunctional. How is communication about strategies of change being done to gain buy-in? How are you going to measure your change initiatives to find out if you’ve been successful?  How are you going to ensure the desired culture is maintained?  There are a number of tools (mostly overseas based) which can be used to start this process. Here is a free online culture change assessment tool you could use.

What is the experience of your resident and your staff on a daily basis?  Would they recommend you to others in a way to reflects loyalty to your care facility as a preferred place to live or work? If not, what are you going to do about it?

When Norovirus hit, the staff hit back!

ONE EXPERIENCE OF NOROVIRUS MANAGEMENT  

Some may think the actions a little extreme but the objective was to minimise risk to others and in doing so, minimise the numbers of people (residents and staff) infected with Norovirus. The below is how one facility dealt with a norovirus outbreak recently.

Here’s how we dealt with what happened in our facility:

With the Clinical Nurse Manager on annual leave at 8.00 am on Friday 11 January the Senior RN advised the QA we had two suspected cases of vomiting and diarrhoea.  At 10.00 am the Senior RN advised the QA we could have four more cases of diarrhoea.

An immediate meeting was called with management and the situation discussed.  The following steps were instigated –

  • We immediately referred to our HCSL Safe and Appropriate Infection Control policy manual.
  • We decided to take the “worst case” scenario approach eg Norovirus.
  • We then set out an “action plan” and held a meeting at 11.00 am with all the staff present to advise the situation and actions to be taken –

Action Plan 

  • Infection Control at DHB were advised and samples were sent for analysis
  • The Rest Home was put into “lock down”. The families and next of kin of all the residents were advised.
  • The Village residents were advised and instructions given to them on procedures to follow.
  • The doors between the three sections of the Rest Home were closed and staff confined to these areas only – no exceptions.
  • The infection log from HCSL system was immediately put into use – an RN had to sight all vomit and diarrhoea together with noting the times and dates – this information was supplied on a daily basis to  DHB – this information was imperative to identify if virus was spreading, how quickly, or if it had been confined to certain areas etc.
  • The RNs appointed “dirty” nurses on each shift. A “clean” person was also appointed for delivering supplies around the whole rest home. Trollies were meticulously sanitised when “travelling” between these areas.
  • Kitchen staff were confined to the kitchen only
  • All residents were confined to their rooms with meals being delivered using “clean” and “dirty” trollies. This may seem extreme but the residents were agreeable to this.
  • Diagrams out of our policy manual were put in the Nurses Stations on how to put on PPE. Full PPE was mandatory in all “dirty” residents rooms and when serving food or drinks.   Face masks were mandatory for all staff at all times – no exceptions.  Full face shields were used in the laundry and any very soiled linen was disposed of as per instructions.
  • Hand washing and sanitising techniques were vigorously adhered to.
  • The cleaners were issued with “heavy duty” cleaning products and all vacuuming was banned.
  • Being an older Rest Home with only certain areas being air conditioned it was easy to turn off all conditioning and keep off.
  • Residents were encouraged to open their windows for fresh air and let in the sunlight.
  • Cleaning equipment was kept in the “dirty” rooms for their use.
  • All residents were advised to put toilet seats down prior to flushing and flush twice.
  • All residents and staff were reminded of hand hygiene practices and we ensured the appropriate supplies of hand washing and hand hygiene gels were available.
  • Communal areas in the Rest Home were closed, cleaned, sanitised and not used.
  • Management held a daily meeting at 9:00am to report on the up to date situation and a report was issued to the staff at 1:00pm and a daily report issued to the DHB.
  • The rest home was advised by DHB ON 16 January 2019 to let residents out of their rooms but stay confined to the areas of the Rest Home they lived in
  • On 21 January 2019 the rest home underwent a complete steam clean of carpets, drapes etc,
  • On 22 January 2019 we re-opened the Rest Home to visitors again.

LESSONS LEARNT

We had a total of  only 4 confirmed cases of Norovirus – one in the hospital and three in the rest home.  At the time the Rest Home was fully occupied (60 residents).

Follow your Policies and Procedures “to the letter”.  Without the excellent information contained in our policy manual we would not have achieved the result we did as everyone had varying views on what to do.  We had only one “view”.

We received congratulations from our DHB on handling this situation and receiving the outcome we did.

And of course we knew we always had the back-up of Gillian at HCSL either via email or telephone if required.

 

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.

Great audit result

Hi Gillian,

Great  news, we did very well with the audit.

The Lead Auditor tells us she cannot see we have any corrective actions to complete!

Also she acknowledged a CI  from one of the Quality Improvements I completed. She was very impressed with the Quality and risk management systems via your Policies and procedures and says we are using your systems to the max.

Well, where would we be without your Policy and Procedures, they are great to work with – thank you.

kind regards

Rose Kennedy (Dixon House – Greymouth)

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.

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.

RN – Manager, Kaiapoi Lodge Resthome and Hospital – February 2017

We are a medium sized rest home and hospital. The complexities of the various standards means that without a product such as HCSL we would find it difficult to function. Health Care Compliance Solutions Ltd has ensured we stay up to date and compliant in all areas of our industry.

The recent introduction of the online tool has been a massive invaluable boost, all staff now have access to the latest documents online.

Never before have we been able to compare ourselves against industry. Instant access to current documents, analysis of events and graphical representation are just a click away. Adverse events and infections are recorded and compared against industry.  The ability to log complaints, restraints and complete internal audit has aided in our ability to close the quality circle.

With HCSL we no longer need to worry about the policies and procedures we just need to focus on the implementation.

 

 

Jonathan Prangnell

Registered Nurse/Manager 

Kaiapoi Lodge Residential Care Ltd  – February 2017