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.
Gillian Robinson – Bachelor of Nursing, Registered Nurse, Lead Auditor, Management Consultant, Author Liz Beaglehole – New Zealand Registered Dietitian, with a Post-graduate Diploma in Dietetics (with distinction), Canterbury Dietitians. Ben Harris – Medical Laboratory Scientist, Honorary Lecturer for the University of Otago
Incorporating clinical and management topics, these study days are designed to provide the opportunity to learn together and gain a greater understanding of each others roles and aged care industry expectations. Gain your professional development hours by joining your colleagues for two fun days of learning.
Topics include:
Day One – Thursday 12th April – 9.00am to 4.30pm
Age-related Residential Care (ARRC) – understanding the DHB funding service specifications
Quality and Risk Management – striving and achieving excellence
Clinical Leadership – how to lead the clinical team effectively
Clinical Documentation – What, when, how and why to document
Clinical Assessment and Care Planning – bringing it all together for better resident outcomes
Microbiome – why understanding this is so important
Multi-Drug Resistant Organisms (MDROs) – the current and pending impact
Day two – Friday 13th April (9.00am start, finish approximately 1.00pm)
Urinary Tract Infections – to dip or not?!
Norovirus and Influenza – latest updates
Food Safety – Food Safety and Nutrition
Question and Answer session
Attendees will supply their own lunch. Morning and afternoon tea will be provided.
Venue: Chapel Street Centre, Cnr Harewood Road and Chapel Street, Papanui, Christchurch. (Easy access from the airport)
Numbers will be limited so register today.
To register – email gill@agedcarecompliance.com and supply the names and designations of each staff member attending, and confirmation if they will be attending day one or day two or both days?
The attendance fee for this content filled education is $155 (plus GST per attendee to cover both days), $85.00 plus GST per attendee to cover either day one or day two.
We will respond with confirmation of registrations. Certificates of attendance will be provided.
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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.
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When undertaking a change management process in care facilities, I’ve identified 5 distinct phases of reaction from managers and staff. These have often occurred after I’ve been appointed to perform the role of statutory (temporary) manager by a DHB. This is generally after risk to residents has been identified following an audit or a serious complaint.
As a temporary manager, often there is a facility manager in place however for a range of reasons doesn’t have the resources or knowledge to meet the needs of the residents to a standard that satisfies audit outcomes.
Phase 1 is on first arriving and there is relief on the part of the staff and manager (if there is one) on the basis they have the view that I’m there to ‘save the day’, make things right and then they can get on with running things. Comments such as “you should have been called in a long time ago” are common.
Phase 2 is where the staff and in place management start to realise that I’m not going to do all the work for them and my role is that of mentor and coach. Further to that the role includes assistance with obtaining necessary resources to support clinical and operational practices. This is where push-back and resistance starts to show as people resist change and try to hold stead-fast to those practices that have got them to the point they’re at. As pressure increases for change to occur, resistance increases and at times sabotage of the new way of doing things starts to appear. As one provider put it recently “they’re ever so nice to your face and will stab you in the back”. The denial phase plays out and the anger phase starts.
Phase 3 is a time when divisions start between those who want to embrace change knowing it’s intended to improve and make the workplace safer for staff and more so, safer for residents; and those who don’t have insight to recognise the need for change. The need for people to remain in their comfort circle doing what’s known and predictable is incredibly strong for a large number of people. This slows momentum and the temporary manager starts to get the blame for things being wrong. Such comments as ‘it was all fine before the DHB stepped in, they just need to back off and let us get on with it’ are also commonplace in this phase. Sometimes senior staff at the facility will contact their DHB and say the temporary manager is unreasonable, not doing anything and needs to be removed. All as an attempt to get rid of the person they see as pushing them outside their comfort circle and affecting maintaining of the status quot. The bargaining phase can continue for quite some time but this often depends on how direct and steadfast the response is to the bargaining strategies.
Phase 4 occurs when there is the start of the depression phase and realising that solid work, participation by all and a willingness to take on new ideas and learn new ways of doing things needs to occur. The real work has started by the willing few in the early phase and continues and now the collective change can start to be evident.
Phase 5 is acceptance that the temporary management or change management process was necessary. Staff start to commend the new way and embrace new ideas recognising that things are actually better now than they’ve been before. As people always have choice about coming on board with change or leaving, invariably there are some staff and sometimes managers or even members of Governance who continue to resist seeing a new way is needed and those few will leave the organisation or continue to resist.
I’m able to observe which phase an organisation is operating in by the response of those working there and was intrigued to read of exactly this same set of steps in a book titled ‘Expert Secrets’ written by Russell Brunson. Some of you who are familiar with the work of Elisabeth Kübler-Ross will also recognise these phases as reflecting her stages of grief.
Acceptance is hard as people take the need for change as a criticism when in my view, people don’t fail; systems do!!
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Mobile app now available for conducting your residential care ARRC specific internal audits.
There are a full range of internal audits pre-loaded ready for use. Collectively, these audits reflect the criteria Certification auditors will be checking.
This process gives you the opportunity to be sure you’re on track with achieving compliance. The findings auto-populate into corrective action tables which prompt timely addressing of these corrective actions. This system syncs with your main computer system and makes reporting to management and Governance boards very easy.
The Certification auditors (after given specific access authority with your permission) are also able to access the results of the internal audits you’ve completed.
To view a brief video on the use of this system, click here.
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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.
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:
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.
Download the app or look at the IDDSI website to familiarise yourself with the framework.
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?
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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Success leaves clues but often these aren’t being picked up so you miss the learning and miss the opportunity to recognise growth or gain continuous improvement in your audits.
In residential care, HealthCert (MoH) Certification processes appear solely to promote a goal of verifying compliance with requirements. Looking deeper however, the goal of meeting requirements ensures the protection and support of those in your care. This can then be evidenced in a way that’s reflective of service received as meaningful, safe and appropriate by individual residents.
It’s no longer an expectation that you’ll have a number of partial attainments as a result of an external audit. The expectation is full compliance and showing evidence of continuous improvement, going over and above the base ‘pass-mark’ brings you into line with your high performing peers. I’ve heard managers say “but it’s the Auditors job to find things wrong so we expect to get partial attainments.” That is out-dated thinking and doesn’t fit the current audit and compliance environment or continuous improvement philosophy.
Systems can’t be implemented to show compliance, if staff are not looking at policies and procedures, or using them to guide services and care of residents. If individual staff or managers do what they think best, based on previous experience, without verifying whether that practice is still appropriate or best practice, they do themselves and residents a disservice.
Success leaves clues. It’s apparent when quality systems are implemented, outcomes are checked in a measurable way, recorded, examined, analysed and greater gains identified for future implementation. This is a cycle and if you have the right tools to record your continuous improvement projects on, you too will be in the elite who are out-performing those who continue to have multiple partial attainments (deficits) in audit. Don’t be a provider that looks at others saying it’s ok for them; they have this or that or the other reason for their success but we don’t have those things so we can’t achieve. Don’t make others extraordinary to let yourself off the hook. You can have, and deserve to have, all the recognition for the amazing work you perform just like others who are achieving four years.
The lack of a robust up to date quality system, along with deficits in implementation, will lead you down an expensive compliance track. Expensive in loss of reputation as audits are published and accessed online by the public, expensive in loss of time trying to figure things out yourself, increased risk to residents, loss of financial resources as you end up being audited more often than would have otherwise been necessary. The better you achieve at audit, the longer your period of certification, the less often you are audited and therefore less often you’re paying auditors fees!
A common failing in the care facilities under Temporary Management has been from the lack of a proven quality system and application of that system into service provision. I’ve been contracted into a number of sites as a Temporary Manager over the years and this has consistently been the case.
If you would like a free Continuous Improvement Project template to help you identify and record your success, contact us and we’ll email it to you.
Our eyes see what is familiar and what they expect to see. Are we good at picking up subtle changes through your assessment processes and acting on them appropriately? The ability to see the less than obvious is essential when responsible for clinical assessment as you won’t act on those things you haven’t noticed.
On the 5th July I presented a full day seminar on a range of topics to Nurses working in aged care. During the day I made what should have been an obvious change but I have no doubt it wasn’t noticed by all. In the morning I wore a dress with a white jacket. In the afternoon I’d changed the dress for one of a different colour and pattern but retained the white jacket. I made the change during the lunch break.
When I entered the room after the lunch break three people commented straight away. I saw a small number of puzzled looks but those nurses didn’t say anything. Others didn’t seem to notice and didn’t make comment. We had three distinct groups. Those that notice and comment, those that notice but don’t comment and those that don’t notice and therefore don’t comment! Which are the nurses you’d feel safest with if it came to performing a clinical assessment on you on an ongoing basis day after day? Which differences would they notice and which wouldn’t get a second glance. Which changes would be commented on?
We need a mix of ‘detail’ thinkers and ‘big picture’ thinkers to see everything that occurs. Equally these two groups of people can complement each other. Working separately they will each only see part of what needs managing. Some over think and others don’t seem to think or reflect. Awareness of how the members of your nursing team work and think could be important in supporting you to minimise risk resulting from subtle changes occurring which may not have been addressed.
It may be beneficial to review personality types to see how your team are working separately or collectively to ensure the best outcome for residents in their care. This increased recognition of each others natural thinking styles may also enhance the ability of the team to understand each other and consciously support others differences. There are a raft of profiling tests however Myers Briggs has been around as a validated tool for a long time and may be a useful one for you and your team.
What subtle changes are occurring with your residents that you haven’t noticed? Did you see the white dress in the morning change to a black one in the afternoon? If not, what else are you not seeing that could expose someone to risk? Are any of your team seeing things but not saying anything because they don’t recognise it’s their responsibility or think someone else has commented?
When care planning, the goals or objectives developed for each aspect of care need to be measurable. This ensures you’re able to evaluate progress and determine whether the goal has been met or not. The concern is making sure an appropriate goal is set. While we look at this from a clinical perspective, we must always remember the resident as the central focus and director where they are able to provide input into what the care plan relays. People have choice within their capacity and sometimes as nurses, we may not agree with a choice made by our patients / residents in aged care.
When guiding weight management goals from a clinical perspective, Liz Beaglehole, Registered Dietitian has offered the below guide.
Ideal weight range in the care process:
Body mass index is still helpful in determining healthy weights for older adults. A healthy BMI range for adults over 65 actually shifts upwards as compared to adults. So a healthy BMI for older adults has been found to be BMI – 22 – 27kg/m2. A BMI above 32kg/m2 would suggest obesity, a BMI below 20 suggests underweight, and below 18.5 is malnourished.
To work out the BMI: (weight/height²). Example case: height = 1.5m and weight = 45kg
We need the height in metres and the weight in Kg.
The height needs to be squared. So a height of 1.5m = 2.25 when squared.
Then the BMI is the weight in Kg divided by the height²
Example: weight = 45kg divided by 2.25 = BMI of 20kg/m². This is regarded as the lower end of ideal body weight and suggests the resident is underweight for optimal health.
An ideal body weight for some who is 1.5m tall would be a BMI range of 22 – 27 so a weight range of min 50kg up to around 60kg. Basically to work out ideal body weight just enter different weights into the BMI calculation until you get to the BMI of at least 22 and then again to a BMI of around 27.
The ideal body weight may differ to the GOAL weight. The goal weight may be something that is set when the BMI is outside the ideal range but some weight changes are desirable. The goal weight is more useful and practical as it considers the weight history of the resident and the ability to achieve changes in weight. For example, a resident may be underweight with a weight of 42kg (BMI= 18.6) but they have been this weight for the past year. Ideally they would gain weight to 50kg, but this is unrealistic. The goal weight therefore becomes either weight stabilisation at 42kg or a slight weight gain to 44kg. This would still mean the resident is underweight but is realistic in what can be achieved. If the initial goal weight is achieved, a second goal weight may be identified. This may be to stabilise weight at 44kg or to gain to 45kg. etc…
This can work for overweight residents too. Using the same example height of 1.5m. Someone who weighs 78kg has a BMI of 34.6, and is obese. However, realistic weight loss to within the ideal body weight range would suggest the resident would need to lose around 18 – 28kg, which is completely unrealistic and would never be suggested for aged care. A more realistic GOAL weight would be weight stabilisation and then some weight loss. 5% weight loss can improve many health outcomes and this would be a realistic target. Weight loss of 5% is still around 4kg, which is possible but still difficult.
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While most of the referrals for dietitian input in aged care facilities relates to unwanted weight loss, dietitians can be asked for input with residents who have unwanted weight gain.
What is overweight?
For many adults we use the Body Mass Index as a basis for identifying a ‘healthy weight range’. The BMI is a ration of the person’s height to their weight. (kg/m²) The BMI is not without its limitations, but generally it is a useful tool in assessing if someone is within the recommended weight range (BMI 20 – 25kg/m²), below it (underweight and malnourished) or above it (overweight and obese). For older adults, the ‘healthy weight range’ tends to shift upwards. There is evidence older adults with a BMI between 22 – 27 kg/m², have a longer life expectancy. There is evidence that older adults who have unwanted weight loss will reduce their life expectancy.
What is the aim?
The first question to ask is whether this weight gain is a cause for health concern, and if there are benefits gained from weight loss. In some cases weight gain may lead to reduced mobility, worsening blood sugar control, exacerbation of shortness of breath and gastric reflux, problems in fitting clothes, problems with ill-fitting hoists, chairs, and increased difficulty with transfers. If it agreed that weight loss would be beneficial, the first nutritional goal is to prevent further weight gain. Aim to stabilise the current weight. Weight loss may be the next goal once weight stabilisation is achieved.
How much weight to lose?
Stabilising the current weight is a good start. If weight loss is desired, set a realistic weight goal with the resident. Health benefits are noticeable with as little as 5% weight loss. A 85kg woman losing around 4kg should notice some benefits.
The goal of weight loss it to be losing body fat, not body muscle. If weight loss is too rapid, the risk is that significant muscle mass is lost. This can lead to worse health outcomes.
Involving the resident who has unwanted weight gain
A discussion with the resident about whether they are noticing any effects from the weight gain, and whether they would like to try and prevent gaining more weight, is essential. It may be useful to explain the expected health benefits possible with weight loss. Family may also like to be consulted, but the decision and the motivation really needs to come from the resident.
Just telling a resident they need to lose weight, or automatically changing their diet is not treating a resident with respect, nor providing care that is tailored to their needs. You may feel that the ‘best’ option would be to lose weight. The resident may feel different. They have the right to choose what’s right for them.
What strategies may help unwanted weight gain?
Losing weight is hard. There needs to be a reduction in the energy intake with an increase in energy output. Changes to food and changes to levels of activity are needed for optimal results. Activity and body movement are important in helping to maintain muscle mass. The diet still needs to remain nutritionally adequate, especially in terms of protein to minimise the loss of body protein too. Continue to offer quality protein foods, at main meals and tea meals.
An aged care facility menu is nutritionally balanced and tailored to ensure the nutritional needs of the residents are met. Talk with the resident about what ideas they might be happy to try to help reduce their food intake. Small changes eventually add up to significant calorie reduction. Start with changing one or two things only in the diet. If that is successful, add in other small changes.
Reducing Food Intake
Target between meal snacks such as morning tea, and/or afternoon tea. If the resident is not hungry at these times, he or she may be able to skip the food offered
Limit sweet drinks; offer water, ‘diet’ options and a sugar replacement in hot drinks
Reduce the frequency of desserts in the week, or offer lower calorie options such as fresh fruit, diet jelly, low fat yoghurt. Limit the use of cream on desserts.
Ensure the size of the main meal is a medium meal (not large), serve extra vegetables if the resident is wanting more food.
Look at the quantity of food eaten at meals. Reducing the amount slightly can help.
Target the amount eaten at ‘happy hours’ and other treat times
Try to encourage the resident to limit the amount of extra foods they may be buying and having in their room
Ask family and friends not to bring in food items. Suggest other options such as magazines, books, photo albums, flowers
Increasing activity levels
Encourage the resident to join in the home’s activities
Encourage the resident to walk more if possible, around the home, to the dining room, around the garden – short distances at first so they gain a sense of achievement
Family and friends may be able to help by joining the resident in walks or taking them on outings too
These are some ideas to try. For more information and tailored nutritional advice contact your clinical dietitian. If the resident is ready to make some changes, offer support and encouragement, to help enable their success. Be positive. As with all of us, sometimes we deviate from our own ‘diet’; we have a treat or a dessert or a second helping. Don’t judge residents, or be so strict with restricting foods. Avoid using phrases that suggest the resident is ‘being good’ or ‘being naughty’ in terms of whether they are following the agreed diet plan. There are no ‘good’ foods and ‘bad’ foods. And finally, weight loss takes time. Simply stalling the weight increase is a significant achievement. Long term encouragement and support is essential for successful and sustained weight loss.
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